Predicting factors for conversion of laparoscopic cholecystectomy to open one

Laparoscopic cholecystectomy has now replaced open cholecystectomy for the treatment of gallbladder diseases. However, certain cases still require conversion to open procedures. So, there is a need to identify risk factors for [a] predicting the probability of conversion preoperatively for selected patients, [b] preparing those patients psychologically, [c] arranging operating schedules accordingly, and [d] minimizing the procedure-related cost, which is a significant problem in developing countries. This study aimed to identify and evaluate risk factors that may predict conversion of laparoscopic cholecystectomy to an open procedure. 200 patients undergoing Laparoscopic cholecystectomy were included in the study. Sonographic findings like gall bladder wall thickness, adhesions around gall bladder and anatomy of Calot's triangle as well as gender, obesity, state of the liver and intra operative findings and/or complications which may supervene were analyzed. Of the 200 patients in whom laparoscopic cholecystectomy was attempted, 17 cases [8.5%] required conversion to open surgery. The most common reasons for conversion were dense adhesions around gall bladder [8cases] representing 47.05% of converted cases and 4% of total cases and gall bladder wall thickness>3mm [3 cases] accounting for 17.64% of total conversion and 1.5% of all cases .Significantly independent predictive factors for conversion were male gender, old age, obesity and liver cirrhosis. Patient factors, disease related factors, preoperative ultrasonography findings, operative findings and of no doubt surgeon's experience, all contribute to predict the possibility of conversion of laparoscopic cholecystectomy. Knowledge of these factors may help in pre-information to patient for psychological preparations for conversion and an experienced surgeon to operate on these patients

Conservative treatment of ingrown toenail

Ingrown toenail or onychocryptosis or unguis incarnates is a common health problem affecting generally young adults and result in a lot of discomfort and a significant morbidity. Though a variety of methods have been adopted including conservative treatment, nail excision and partial complete matrixectomy, but to date no ideal treatment exists. Although conservative management was first described in the eighteenth century and has been reported sporadically since, only a few doctors treat their patients in this way. There is, however, a distinct place for this highly effective, low cost method as the initial treatment of these patients without the need for hospital referral. The study was carried out on 25 patients with 29 ingrown toenails in whom there is over curvature of the nail plate as one of the etiological factors for that condition. The central portion of the nail is scrapped using a scalpel making it more pliable at edges and corners so could be lifted from heaped soft tissues over. After that the patients were instructed to cut their nail straight and to repeat the procedure of scrapping, they have been learned, when need supervenes. In patients not benefited from this simple technique wedge resection with phenol matrixectomy was performed for them. The patients' age ranged from 10 to 53 years with a mean age of 28 years In all patients it was the big toe that was affected. Four patients had bilateral ingrown toenail, so the sum was 29 ingrown toenails .Five patients of the twenty one with one toe affection did not satisfy by the conservative treatment and subjected to wedge excision and phenol matrixectomy. After 24 hrs, patients in whom conservative treatment was applied were able to move around. By the end of second week, they were able to attend to their normal work. Healing was complete by 4 weeks in the twenty patients. Success rate was 82.75% [24 of 29 ingrown toenails]. Conservative treatment is a worthy trial for patients with ingrown toe nail especially in the early stages of the disease in which the primary cause is increased curvature of the nail. Although it needs a highly cooperative patient, it is painless, requires no anesthesia and achieves a high success rate

incidence of malignancy in egyptian women presenting with nipple discharge

Nipple discharge causes a degree of anxiety in women because of fear of breast cancer. Commonly, the absence of palpable or mammographic abnormalities gives a false sense of security, causing delays in diagnosis. Mammography, ultrasound, and cytology are useful only when positive, but have a high rate of false-negative results and do not preclude histological diagnosis. The aim of this study is to detect incidence of malignancy in Egyptian women presenting with nipple discharge and protocol for their management. Forty patients with pathological nipple discharge were included in the study and offered operation. Patients with surgically significant nipple discharge only of 40 years and above are recommended to undergo radical subareolar duct excision [Hadfield's procedure]. Patients below 40 years of age, particularly if intending to breast feed, with persistent discharge are given the option of microdochectomy. All histopathology results were reviewed. Patients were divided into two groups - those with red blood cells [RBCs] present in the nipple discharge and those without. Forty consecutive patients underwent operation for isolated nipple discharge during the study period. Median age was 54 years [range, 32-79 years]: Analysis of nipple discharge revealed RBCs in 16 patients [40%]. The remainder, 24[60%], had no RBCs on analysis of nipple discharge. Thirty seven patients [92.5%] underwent radical subareolar duct excision [Hadfield's procedure] and 3 patients [7.5%] microdochectomy. Histopathology revealed all patients with RBCs -positive nipple discharge had benign disease -7 [43.75%] had an intraductal papilloma and 9 [56.25%] had duct ectasia. Most patients with RBCs negative nipple discharge had benign disease - 4 [16.6%] had intraductal papilloma and 18 [75%] duct ectasia while the remaining two [8.33%] had in situ carcinoma. Despite the various tests used in the assessment of pathological nipple discharge, this study highlights their limited help at predicting the cause. This, together with several other studies, demonstrates that ductal surgery remains the only reliable way of providing a diagnosis, in addition to being the ideal therapeutic measure