Modified endocystectomy versus pericystectomy in echinococcus granulosus liver cysts: a randomized controlled study and the role of specific anti-hydatid iGG4 in detection of early recurrence

The evidence based data of hydatid liver disease indicate that the level of evidence was too low to help decide between radical or conservative surgeries [level IV evidence, grade C recommendation]. So, there is a need for accurately designed randomized trials with precise goals to compare pericystes-tomy versus a specific modified endocystectomy technique for the treatment of hepatic hydatid cysts 8 cm or less in diameter in Egyptian patients, regarding the operative time, intra-opera-tive blood loss, complications and long term recurrence and to test the role of anti-hydatid IgG4 in diagnosis and detection of early recurrence. 60Patients with 131 liver cysts of E. granu-losus fulfilling the study criteria were randomly divided to two groups. G1: 32 patients with 69custs treated by modified endo-cystectomy and GII: 28 patients with 62cysts treated by closed total pericystectomy. GIa included 40cysts >5cm in diameter [mean 6.86, SD +/- 0.809] and GIb29cysts5cm in diame-ter [mean 7.01 SD +/- 0.79] and GIIb25cysts >/-cm in diameter [mean 4.04 SD +/- 0.93]. Preoperative evaluation inclyded histo-ry taking, clinical examination, blood tests, specific anti-hydat-id IgG4, abdominal sonography and CT scan. The operative time for dealing with each cyst was in minutes. Operative blood loss and need for blood trancfusion were estimated for each patient. Specific anti-hydatid IgG4 by ELISA was used to diagnose and to detect early rasurrence. Patients were followed up clinically and by ultrasonography every 3 months and for anti-hydatid IgG4 every 6 months for 24-90 months. The mean maximum operative time was in GIIa followed by GIa, GIb, then GIIb. The operative time was significantly lower in GIIb than Ib and in GIa than IIa. Seven patients [GII] had blood transfusion. The intraoperative bleeding in GI was <500ml/patient, and 18patients [GII] each bled >500ml. No intra-peritoneal seedling during the follow up. Five of 55patients [9%] were serologically suspected of relapse or incomplete cure. One [GII] showed early recurrence at 3 months. High IgG4 antibodies were detected in patients which decreased gradually after surgery and normal after 18 months post-operation.

Primary repair versus colostomy in management of penetrating colonic injuries

There has been a change in perspective in the treatment of penetrating injuries of the colon. The aim of the study is to compare between colostomy and primary repair and in particular to determine whether the latter is safe when there is operative delay, in the presence of intra-abdominal contamination, associated injuries and/or shock. Forty-eight patients with penetrating colonic injuries were randomly treated by primary closure or colostomy. There were significant differences between the two treatment groups as regards the operating time [primary repair; mean 132.2 mm, range 65-220 and colostomy; mean 148.7 mm, range 71-288] and the time of hospital stay [primary repair; mean 10 days, range 7-52 and colostomy; mean 29 days, range 21-63]. There were no significant difference between the two treatment groups as regards the operative delay and the postoperative complications. It is concluded that primary repair is a safe procedure in managing penetrating colonic injuries irrespective of delay, or other adverse circumstances

Elective surgical repair of groin hernias with mesh versus herniorraphy in ascitic liver patients

To initially evaluate the possibility of electively repairing groin hernias in ascitic liver patients, to test the feasibility of the use of mesh in these patients and to evaluate mesh repair versus herniorraphy, 30 patients' [3 females and 27 males] with liver ascites and uncomplicated groin hernias were treated operatively for their hernias. They were divided into two groups: group I [Gp I]: 14 patients [9 indirect, 3 direct and 2 femoral] treated by herniorraphy and group II [Gp II]: 16 patients [10 indirect, 3 direct, 3 femoral] treated by polypropylene mesh placement with or without plug. All operations were performed under local anesthesia with preoperative prophylactic antibiotic cover. 23 patients were followed up: 11 in Gp I [4 to 24 months mean = 14.82 SD, 6.08] and 12 in group II [7 to 28 months mean = 14.42 SD, 5 98] Seventeen ascitic fluid samples were taken intra-operatively for bacteriological study. There was no operative mortality. Post operative complications included : temporary increase in ascites which occurred in 25 patients [12 in group [I], 13 group[II]]. In 21 cases. It responded to medical treatment and in three it required paracentesis. There was no deep wound infection. There were three cases of superficial wound infection [2 in group I and one in group II]. Scrotal hematoma and/or seroma occurred in four cases. A major attack of variceal bleeding occurred in a patient in the mesh group and was treated successfully. There was no spontaneous bacterial peritonitis. There were three recurrences: two in Gp I and one in Gp II. two of the recurrences were attributed to technical mistakes. Five [29.41%] of the bacteriological samples showed mono-microbial organisms i.e. bacterascites. Three were gram-ve two of them were E coli and one Pantoea spp. and two were Gram +ve Staph aureus [one was methicillin resistant] Findings indicate that elective groin hernia repair in liver patients with ascites is feasible even without prior peritoneovenous shunting with no mortality and an acceptable overall rate of complication. The use of mesh seems justified in -those patients with comparable of not superior, results to herniorraphy. Mesh placement was not associated with any increase in the rate of complications or wound infection .Although no spontaneous bacterial peritonitis occurred in this .study, caution should be taken and long antibiotic cover is probably important to avoid this fatal complication because bacterascites was found in 29 41% of the patients

Pre-operative MRI evaluation of local disease extent in residual / recurrent colorectal and anal cancer

To determine pre-operative MRI accuracy in assessing local disease extent in residual / recurrent colorectal and anal cancer by comparing MRI assessment and staging examination under anaesthesia, Eighteen consecutive patients with recurrent [12 patients] or residual [6 patients] underwent examination under anaesthesia and MRI using a phased array pelvic coil. .Analysis of eight specific anatomical regions for tumor involvement on MRI was performed Findings at examination under anaesthesia and biopsy were recorded. The MRI and examination under anaesthesia findings were correlated with findings at surgery and histopathology. MRI accuracy in determining tumor invasion for all sites assessed were [90%,], sensitivity was [85%,], specificity was [91%], positive predictive value [PPV] was [75%] and negative predictive value [NPV] was [95%]. For those anatomical sites evaluated by both examination under anaesthesia and MRI, MRI was superior to examination under anaesthesia, with an accuracy of 90% Vs 74%. MRI is an accurate technique for assessing disease extent in recurrent / residual colorectal and anal cancer

Cholelithiasis in cirrhosis: features in a group of Egyptian cholecystectomy candidates

To investigate the main features [stone type and others] of cholelithiasis in a group of Egyptian cirrhotics undergoing cholecystectomy by studying them versus hepatosteatotic and normal liver cholecystectomy candidates, 200 consecutive Egyptian patients undergoing cholecystectomy for cholelithiasis were studied. According to their liver condition, they were divided into three groups: Frank cirrhosis, hepatosteatosis and normal liver. The three groups were compared regarding the stone type by gross appearance and chemical analysis, nature of cholecystitis, incidence, gender and gallbladder bile crystallization. There were 19 cirrhotics, 33 hepatosteatotics and 148 normal liver patients. In the cirrhotic group [10 males and 9 females], 18 had pigment stones, one had mixed stone and none had cholesterol stones. None of the bile specimens were crystallized in this group. In the hepatosteatosis group [4 males and 29 females], 7 had pigment stones, 22 mixed and 4 cholesterol. In the normal liver group [27 males and 121 females], 24 had pigment stones, 99 had mixed stones and 25 had cholesterol stones. Gallbladder bile crystallization in groups II and III matched more with the type of stone than with the liver condition. Stone type and male to female ratio differed significantly between group I and either of groups II and III, whereas the latter two groups were not significantly different