Clinical impacts of oral gastrografin follow through in adhesive small bowel obstruction [ASBO]. [a prospective randomized study]

Many studies have shown that Gastrografin can be used for diagnosis of adhesive small bowel obstruction [ASBO] and for assessing the need for surgical intervention .However; several the studies have reported conflicting results. Therefore the aim of this study is to assess the diagnostic and therapeutic effect of Gastrografin in ASBO. Altogether 110 patients with ASBO were randomized into control and Gastrografin groups. In the Gastrografin group, 100 ml of the dye was administered through a nasogastric tube. Obstruction was considered complete if the contrast failed to reach the colon on the 24-hour film. Patients with Gastrografin in the colon within 24 hours after dye administration were considered as partially obstructed and were submitted to non operative treatment. The patients were operated on if they developed signs of strangulation or failed to improve within 48 hours. The overall operative rate 14.5% in Gastrografin group versus 34.5% in control group: P = 0.04 .The time from admission to resolution of symptoms was significantly lower in Gastrografin group [19.5 vs. 42.6 hours: P = 0.001] and the length of hospital stay shorter in Gastrografin group [3.8 vs. 6.9 days 0.002] and in non operative patients [3.1 vs. 5.1 days]. Sensitivity, specificity, positive predictive value and negative predictive value for Gastrogrqfin follow-through as an indicator for operative treatment of ASBO were 87.5%, 100%, 100%, and 97.9% respectively. Oral Gastrografin helps in the management of ASBO. Oral Gastrografin is safe and reduces the operative rate and time of resolution as well as hospital stay

Trans-perineal VS. trans-rectal repair of rectocele in obstructed defecation: a prospective randomized trial

To evaluate functional outcome of transperineal [TP] versus transrectal [TR] repair of rectocele presented with obstructed defecation. 48 multiparous females with obstructed defecation due to rectocele were randomly allocated into 3 groups: Group A [16 patients]: TP repair with levatorplasty [LP].Group B [16]: TP repair without LP.Group C [16]: TR repair. The study included defecographic assessment, anal manometry / /[Maximum anal resting pressure [MARP], maximum reflex volume [MRV] and urge to defecate volume [UTDV] and functional score [0 -26]. These were done preoperative and 6 months postoperative. Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in the groups of transperineal but not in transrectal repair. We had significant reduction in MARP, UTDV and MRV only in transperineal approach. Functional score was significantly improved in group A [P<0.001] and B [P<0.001] while the improvement was insignificant in group C. LP significantly improved the overall functional score in group A compared to group B and C [P= 0.032] Rectocele repair improves anorectal function by improving the rectal urge sensitivity. TP repair of rectocele is superior to TR repair in both the structural and functional outcome. Levatorplasty improves functional outcome, but should be avoided in young sexually active females

Proximally based versus distally based gluteus muscle flap in treatment of end stage fecal incontinence

To compare proximally based versus distally based gluteus maximus muscle flap transposition in patients with end stage fecal incontinence. Between August 2005 and August 2007, this prospective randomized study was performed on twenty patients with an end stage anal incontinence. They were sixteen men and four women with an age ranging from 7 to 31 years. A proximally based gluteus maximus flap [group III] was carried out in ten patients while, a distally based flap [group I] was done in the other ten. Patients were followed up for 6 - 18 months both subjectively and objectively with evaluation of their incontinence score, anorectal manometry, saline enema test and magnetic resonance imaging [MRI]. Overall, 6/10 patients [60%] in group I and 8/10 patients [80%] in group II were clinically improved with down staging of their incontinence scores from C3 to 0 [P 0.003 and 0.0001 respectively]. This was confirmed by the significant changes in anorectal manometry and saline enema test. MRI done one month postoperatively showed disruption in three patients. Proximally based gluteoplasty appears to be an excellent encirclement procedure that restores voluntary squeeze pressure as well as rectal sensation when compared with unilateral distally based gluteoplasty

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

Comparative study between open vs closed methods of partial division of puborectalis in treating patients with anismus

To revive the results of partial division of the puborectalis and to compare the efficacy of open and a newly designed closed method in treatment of anismus. This prospective randomized study included 30 patients. They were 29 males and one female, with a mean age 42.30 +/- 13.01 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 who underwent bilateral open division of the puborectalis and group [II]: included 15 patients who underwent bilateral closed method. Follow up was conducted for about one year. Improvement was considered when patients returned to their normal habits. Both open and closed methods significantly reduced the preoperative constipation scores. There was 100% initial success. Long term success existed only in 66.6% and 53.3% in group [I] and [II] respectively with no significant difference between the two methods [chi 2:0.556-P: 0.456]. Recurrence was observed in 5 and 7 patients following open and closed methods respectively. Minor degrees of incontinence were confronted in 13.3% in each group with no significant difference. Bilateral partial; division of puborectalis was found to be an effective method in treatment of anismus. Moreover, closed method seems to be simple and attractive

Manometric studies, endorectal ultrasound and incontinence score after closed lateral conventional and tailored sphincterotomy: a randomized prospective study

Purpose: this prospective study was undertaken to compare lateral conventional [CLIS] versus tailored lateral Sphincterotomy [TLIS] in treatment of chronic anal fissure as regards Manometric studies patient acceptance, aling, recurrence and continence disorders

Methods: in the period from July 2001 to March 2002, this study included 42 patients suffering from chronic anal fissure. They were randomized into Group [A] that included 22 patients who were subjected to [CLIS] a d Group [B] that included 20 patients who were subjected to [TLIS]. Preoperative anorectal Manometric studies and endoanal ultrasound [EAUS] were done. Patients were followed up for n period of 3- 12 months

Results: healing of anal fissures had occurred within 4-6 weeks in almost all patients. 15% in-group B developed recurrence of the fissure within two months 31.8% in group A, reported diminished ability to differentiate between flatus and liquid stool. This was transient in 18.2% but continued in 13.6%. In-group B, 10% suffered transient soiling. Postoperative Manometric evaluation revealed significant decrease in both maximum resting and squeeze pressures and significant increase in the resting CV following both CLIS and TLIS. Also, Ultrasound evaluation have confuted the competence of sphincterotomy in 39/42 patients [92.9%]

Conclusion: incontinence is directly related to the extent of muscle division at internal sphincterotomy and that the success rate of TLIS closely approximates that of CLIS with preservation of more anal sphincter muscle and physiology

Antibiotic prophylaxis in elective laparoscopic cholecystectomy: a prospective study

Aim: laparoscopic cholecystectomy gives rise to a very complicated issue concerning the use of antimicrobial prophylaxis. The role of antibiotic prophylaxis in elective laparoscopic cholecystectomy and the relation between post-operative septic complication and bile microbiology will be assessed in this study

Patients and methods: 64 patients were included in the study and divided into two groups; group A: [29 patients] received antibiotic prophylaxis [cefotaxime] and group B [35 patients] received 100m1 isotonic saline [placebo]. Bile sampling and culture was taken for all cases and the patients' were followed up for incidence of sepsis where the wounds were swapped and cultured

Results: bile sampling and culture revealed no growth in 41 cases [64.1%] [19 in-group A and 22 in-group B]. Postoperative infection developed in two cases of group A and in three cases of group, B. Incidence of wound infection was significantly related to incidence of GB perforation [p < 0.0001]. Swabbing of infected wounds and collections revealed infecting organisms other than that detected in bile culture except in one case of group B

Conclusion: there is no relation between bile microbiology and postoperative infection, so, antibiotic prophylaxis is to be used in high-risk patients and in patients suspected to have difficult operation and GB perforation

Asymmetric excision and primary closure with a lateralized wound for sacrococcygeal pilonidal disease is a simple and effective treatment

Aim: this prospective study was undertaken to evaluate the results after asymmetric excision and primary closure with a lateralized wound in patients with Sacrococcygeal pilonidal sinus disease [SPSD]

Methods: from February 2002 to November 2004, a total number of 40 patients with SPSD [recurrent in 9 patients] were treated by asymmetric excision and primary closure with a lateralized wound in our colorectal surgery unit. They were 32 males and 8 females with a mean age 26.02 years. Patients were followed up thereafter for about 6- 31 months [mean 20.02 +/- 6.49]

Results: recurrence had occurred in 2[5%] patients; wound infection had occurred in 1[2.5%] patient, and dehiscence in 2[5%] patients and subcutaneous seroma in 3 [7.5%] patients. the mean hospital stay was 6.6 +/- 2.2 days and complete healing was achieved in a mean period of 15.8 days

Conclusion: the asymmetric excision with a lateralized wound closure is simple and excellent option for treatment of primary or recurrent SPSD with a low recurrence rate, low morbidity, short hospital stay and good long-term results

Repair of anal stenosis: Y-V or diamond pedicle flap anoplasty [comparative randomized study]

Purpose: Anal stenosis is a rare ,incapacitating, and challenging condition, occurring mainly after hemorrhoidectomy, for which several surgical techniques have been devised this comparative randomized study was carried out for patients with severe anal stenosis to evaluate the complication rate, recurrence of anal stenosis and long term outcome after Y-V and diamond pedicle flap anoplasty

Methods: In this study we reported 20 patients with severe postsurgical anal stenosis, 10 of them Underwent Y-V anaplasty while the other 10 had a diamond pedicle flap anoplasty . Sixteen of 20 patients underwent unilateral anaplasty end the remaining 4 patients underwent bilateral anaplasty . A Partial lateral internal sphincterotomy was performed in 16 patients who had a fibrotic muscular component contributing to stenosis All patients were seen every week until complete wound healing was achieved, then every 2 months for 6 months then every year after surgery with a mean follow up 28.6 +/- 4.56

Results: Early postoperative complications was moderate purities in one patient [10 %] who underwent diamond flap anoplasty, while temporary incontinence to gas and liquid stool in 20% , moderate pruritis in 10%, suture dehiscence in 10% and ischaemic contracture of the leading edge of the flap in 20% of cases who underwent Y-V anaplasty. At one month follow up. All patients showed complete wound healing and most of them reported satisfactory results. Two months follow up one patient [10%] with diamond flap complained of mild constipation while 30% of patients with Y-V anoplasty complained of moderate constipation. Six months later neither further complications nor incontinence was observed and anorectal. manometric studies revealed within normal resting and squeeze anal canal pressures for all patients . At one year follow up all patients with a diamond flap showed complete remission of their symptomatology and reported satisfactory results. While 70% of patients who underwent Y-V anoplasty judged their clinical results satisfactory and 30% of them had re-stenosis

Conclusion: Y-V and diamond flap anoplasty are two simple and safe methods for repair of postsurgical anal stenosis, however diamond flap anoplasty seems to be more safe and efficient method with good long term results

Utility of preoperative serum carcinoemberyonic antigen in colorectal cancer patients

Background and Aim: the usefulness of preoperative Carcinoembryonic antigen [CEA] in colorectal cancer [CRC] remains unsettled as regards its role in management and follow up of CRC patients. Efficacy of basal CEA in the diagnosis, prognosis, follow up and therapy of CRC patients will be assessed in this study

Patients and Methods: 200 CRC patients and 100 persons as a healthy control were included in the study. Basal CEA was done before resection. Postoperative Dukes' staging was adopted. Routine follow up and CEA estimation were done

Results: the mean CEA in CRC patients [17.3 ng% +/- 1.67] was significantly higher than control [3.41 ng% +/- 1.1]. A significant association between mean basal CEA and Dukes' classes was evident [it was 7.8, 12.7, 25.8 ng% for Dukes' A, B, C]. The validity of basal CEA in primary CRC diagnosis was highly positive, with higher efficacy in advanced disease detection and negative exclusion power for DFS prediction. Basal CEA was a discriminant factor in prognosis. DFT and DFS were higher in patients with CEA

Conclusion: the preoperative CEA identifies subsets with favourable, indolent and uneven biological behaviour [ 15 ng %]. With conventional staging, it forms strong prognostic tool that supplies practice guideline for follow up and therapy

Lymphatic drainage of the female breast: a surgical perspective

Although the origin of breast lymphatic 'napping dates back to the 17th and 18th century, until recently the lymphatic drainage of the breast has been poorly understood. These old classic studies of the lymnphatic drainage of the breast were based on cadaveric or postoperative specimens. A different view currently prevails; more recent studies were done, reviewed during surgical procedures when the lymphatics of the breast are in active physiologic process allowing the lymph to flow. Lymphatic napping with sentinel nod biopsy is an essential component of staging patients with breast cancer and is rapidly becoming recognized and accepted means of assessing regional lymph node status for multiple tumors including the breast. This study evaluated 23 patients with breast cancer. These 23 patients were divided as follows al 23 patients were injected with 99 Tc -albumin nanocolloid 1-3 days preoperatively. Intraoperatively during the surgical procedure: 8 patients with unicentric breast cancer were injected with the methylene blue dye subareolarly, 3 patients with multicentric breast cancer were injected with the mnethylene blue dye in the dominant tumor, 4 patients with unicentric breast cancer were injected with the blue [dye in a Separate quadrant [discordant quadrant] away from the tumor in patients with clinical diagnosis of T1 N0 or T2 N0 breast cancer. The remaining 8 patients were T1N1M0 or T2-3 N0-1 M0 invasive breast cancel and were included in the study after receiving neoadjuvant chemotherapy then were injected with the blue dye subareolarly. The visualization rate of routine preoperative lymphoscintigraphy was 22/23 [96.5%], i e at least one sentinel node was visualized in 22 out of 23 patients. A total of 31 nodes were depicted in 24 basins. Lymphatic drainage exclusively to the axilla was observed in 20 patients. Two patients had drainage to both the axilla and other non-axillary basins: to the internal mamary chain in one patient and to the infraclavicular.fossa in one patient. During axillary dissection a lymphatic trunk was typically found in most cases heading towards a totally or partially blue or a non blue lymph node. A total of 21 sentinel lymph nodes were identified using the blue dye techniques [21/23] leading to a Success rate of 91.3%.In the lesions with successful SLN localization, an average of 1.6 +/- 0.4 SLNs were removed. The SLNs were metastatic in 10 patients of 21 [47.6%]. In 3 patients, the SLN was the only positive lymph node among the patients with metastasis, the number of involved nodes ranged from 1 to 9. The false-negative rate was 0 or the 21 patients with positive sentinel nodes. Through experience with sentinel node biopsy we can conclude that, axillary drainage is the principle lymphatic path of the breast, rarely any [Drainage pattern from any], quadrant of the breast can occur. Second, most lymph from the breast flows to the nodal basins with a direct course, not passing through the subareolar plexus. Our results support the hypoihes is that the lymphatic drainage of the breast parenchymna and the subareolar plexus leads to the value sentinel lymph node

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