Controversies in surgical intervention and percutaneous biliary drainage for malignant obstructive Jaundice

Management of malignant jaundice is frequently a real challenge. Most patients present in advanced stages of the disease, and usually there are co-morbidities. Some investigations may not be diagnostic or conclusive. There are controversies about the diagnostic and therapeutic procedures for jaundice. Surgical intervention and percutaneous biliary drainage are two lines of treatment with much controversy. Of this work was to assess the controversies in the management of malignant obstructive jaundice as regards benefits, drawbacks and basis of selection of surgical intervention versus percutaneous biliary drainage. 37 patients were included in this study. Detailed medical history, clinical examination and complete y laboratory and imaging investigations for the hepato-biliaiy tract were done. Decision of treatment was guided by the data of the patients, stage and extent of the disease, expected morbidity of the procedure and expected prognosis. 23 males and 14 females with mean age 58.6 +/- 17.4 years were studied. Diagnosis of the studied patients included 17 [45.9%] patients with pancreatic head carcinoma, 12 [32.4%] patients with cholangiocarcinoma, 6 [16.2%] patients with periampullary tumours, one [2.7%] patient with intrahepatic metastatic tumour one [2.7%] patient with hepatocellular carcinoma. Resectable tumours were found in 4 [10.8%] patients, while unresectable tumours were found in 33 [89.2%] patients. The treatment of the patients included surgical intervention for 14 [37.8%] patients and percutaneous biliary drainage for 23 [62.1%] patients. The mean survival duration was 11 +/- 4.8 months after resectional surgery, 6.5 +/- 2.4 months after palliative surgical bypass, while it was 4.7 +/- 1.2 months after percutaneous biliary drainage. Selection of therapeutic procedure was guided and individualized by the data of the patient. Whenever the tumour is operable, resectional surgery is the treatment of choice. However, in the majority of patients, the tumours were inoperable and treatment was palliative. Palliative surgical bypass was associated with less morbidity and longer survival than stenting, and was preferable for lower biliary obstruction. However, precutaneous biliary drainage was more suitable for hilar biliary obstruction. It can be the sole therapeutic procedure for jaundice of patients unfit for surgical intervention. Percutaneous biliary drainage was beneficial for patients with advanced inoperable tumours, with bad general conditions and deteriorated uncorrectable liver functions. It also included diagnostic cholangiography, especially 1 ERCP is not feasible, allowed internal/external drainage and the simultaneous positioning of several protheses

predictive value of C-reactive protein for some clinical and biochemical disorders in patients with chronic renal failure

The present work aimed to study the possible role of inflammatory process in the pathogenesis of anemia, malnutrition. ischemic heart disease, half and half nail sign dyslipidemia and hypoalbuminemia in patients with chronic renal failure under hemodialysis and the predictive value of C-reactive protein [CRP] in these disorders. The subjects of this work comprised of fifty patients with chronic renal failure in the Nephrology unit Benha University Hospital. They were divided into two groups including twenty patients under conservative treatment and thirty patients under regular hemodialysis treatment: 10 patients using polysulphone dialyzers and 20 patients using cuprophane dialyzers. In addition ten healthy subjects were used as controls. For all of them the following was done; full medical history, complete clinical examination, hematological parameters [Hb. content, Nt value, complete blood picture, mean corpuscular volume, mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration], biochemical tests [blood urea, serum creatinine, serum albumin, serum cholesterol and C-reactive protein] and electrocardiogram. The results showed that CRP level in chronic renal failure patients either under conservative treatment or hemodialysis was elevated [12 +/- 3.980 mg/dL and 11.73 +/- 8.081 mg/dL respectively] as compared to the control group [1.85 +/- 1.1 mg/dL] and p<0.05. There was no significant difference between group with conservative treatment and group with hemodialysis [p>0.05]. CRP level was higher in patients using cuprophane dialyzers than patients using polysulphone dialyzers [14.7 +/- 8.3 mg/dl vs 5.8 +/- 2.3 mg/dL] and p<0.05. Hemoglobin concentration was statistically insignificant between patients dialyzed by euprophane or polysulphone [mean value 8.3 +/- 2.6 gm/dl vs 9.9 +/- 2.6 gm/dl, p>0.05]. CRP level was negatively correlated with serum albumin level in CRF under hemodialysis patients [r=0.409 and p<0.05]. Serum albumin level was significantly higher in patients dialyzed by polysulphone than those dialyzed by cuprophane [mean value 4.11 +/- 0.66 gm/dl vs 3.33 +/- 0.89 gm/dl, p<0.05]. CRP level was not correlated with occurrence of half and half nail sign in hemodialysis patients [r=0.25, p>0.05]. CRP level was not correlated with serum total cholesterol level in hemodialysis patients [r=0.13221, p>0.05] while there was high incidence of ischemic ECG changes in those patients. High CRP levels were associated with by and low body mass index in hemodialysis patients, this signifies that inflammatory process contributes in occurrence of malnutrition in hemodialysis patients. Thus we have concluded that, inflammatory process contributes to anaemia, malnutrition, ischemic heart disease and hypoalbuminemia in hemodialysis patients a: C-reactive protein can predict these disorders. The use of biocompatable membranes for dialysis leads to less inflammatory process and consequently better nutrition. state of the patients

Coloid cysts: endoscopic VS. microsurgical treatment

Twenty patients with colloid cysts of the third ventricle had operative procedures for excision in the period from October 1995 to October 2000 [5 years]. Ten cases had microneurosurgical excision [7 cases via transcallosal-transventricular approach and 3 cases via transcortical-transventricular approach]. The other ten [10] patients had transcortical endoscopic excision. There was 12 men and 8 women, and the age of patients ranged from 12-60 years [mean 38.5]. The most common clinical symptoms of both groups included headache [in all patients], diplopia, syncope, ataxia, vertigo, memory deficits and seizure. Papilloedema was present in the majority of cases [70%]. All survived patients had follow-up ranged from 6 months to 36 months [mean 22.5 months]. The results of this study revealed that endoscopic removal of colloid cyst is promising technique that saves the operative and recovery time and decreases the risks of complications

Posttraumatic vegetative patients: clinical and MRI study

This prospective study was carried out on 36 severely head injured patients who were in a vegetative state 6-8 weeks after trauma and had minimal or no CT findings. They were 26 males and 10 females with age range from 6-38 years. The initial Glasgow Coma Score [GCS] of the patients after resuscitation ranged from 4-7 and pupillary abnormalities were noticed in 4 patients. Apart from a small rim of acute subdural hematoma in 2 patients and diffuse brain swelling in 3, initial CT scan did not show significant findings. Follow up CT scan 6-8 weeks after trauma showed cortical atrophy and subdural hygroma in 5 patients. Non of the patients had sustained episodes of hypotension, hypoxemia or severe medical problems. Cerebral MRI was done 6-8 weeks after trauma. In all 36 patients it demonstrated lesions that were not evident on initial or repeated CT scans. By one year, 20 patients had recovered to variable degrees and 16 patients remained vegetative. Seventy five percent of patients who persisted in a vegetative state had an initial GCS of /= 6. MRI showed corpus callosum injury in 94% of patients who remained vegetative in comparison to only 25% of patients who recovered. Brain stem injury was detected in 88% of non-recovered patients and in 5% of recovered patients. Cortical contusion was detected in 44% of non-recovered patients versus 40% of the recovered group. Thalamic lesions were found in 20% of the non-recovered group versus 15% in the recovered group. The results of this study showed that: 1] MRI is more sensitive than CT scanning in the detection of posttraumatic cerebral lesions during the subacute stage after head injury. 2] Initial GCS in addition to MRI findings may help in the prediction of outcome of posttraumatic vegetative patients. 3] injury to the corpus callosum and/or brain stem are highly significant in prediction of non-recovery