Splenic auto-transplantation after splenectomy for trauma: evaluation of a new technique.

BACKGROUND: Splenic autotransplantation is a promising method to recover splenic functions after traumatic splenectomy. However, it is associated with several postoperative complications, such as subphrenic abscess, intestinal obstruction and torsion of the omentum with necrosis of the implanted splenic tissues. Therefore, the aim of this study is to evaluate a new splenic autotransplantation technique that could overcome those complications. MATERIALS AND METHODS: A single segment of the spleen was implanted inside a pedunculated omental pouch and fixed in the native site of the spleen in 15 patients who underwent splenectomy for abdominal trauma. This group of patients was compared with the next 17 patients who underwent splenectomy alone. Additionally, splenic functions of the patient and control groups were evaluated 3 months using peripheral blood smear [the presence of Howell-Jolly (HJ) bodies] and abdominal contrast-enhanced computed tomography (CECT). RESULTS: All patients who underwent splenic autotransplantation showed evidence of a well-vascularised splenic tissue on CECT and normal peripheral blood smear without HJ bodies 3 months postoperatively. No postoperative complications related to splenic autotransplantation were observed, and platelet count after 3 months was significantly higher in patients who underwent splenectomy only (p = 0.04). CONCLUSIONS: Splenic autotransplantation using the aforementioned technique could restore splenic functions with minimum postoperative complications related to the procedure.

Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study.

BACKGROUND: The modified Karydakis flap and the modified Limberg flap are commonly used in the surgical management of sacrococcygeal pilonidal sinus disease. OBJECTIVE: The study aimed to compare short- term results of these techniques. DESIGN: The modified Karydakis flap and the modified Limberg flap were compared in a randomized controlled trial. SETTINGS: The study was conducted in the day-case surgery department of a large academic teaching hospital in Alexandria, Egypt, from February 2009 through September 2011. PATIENTS: Patients undergoing surgery for chronic sacrococcygeal pilonidal sinus disease were eligible for the study. Patients with sepsis were eligible only after aggressive treatment to eliminate sepsis. INTERVENTIONS: Patients were randomly allocated to undergo surgery with either the modified Karydakis flap or the modified Limberg flap. MAIN OUTCOME MEASURES: The primary end point was operative time. Secondary endpoints included proportion of patients with postoperative complications, proportion of patients who were satisfied with the cosmetic results, and the rate of recurrence. LIMITATIONS: Follow-up times were not sufficient to evaluate long-term recurrence rates. RESULTS: Of 154 patients screened, 125 were enrolled, and 120 patients completed the study. The median operative time was significantly shorter in patients with the modified Karydakis flap than in those with the modified Limberg flap: 33 (range, 28-40) min vs 52 (range, 48-62) min; p < 0.001). No significant differences were found between study groups regarding overall complication rate (23% vs 40%, p = 0.08), wound infection (3% vs 5%, p > 0.99), subcutaneous fluid collection (5% vs 0%, p = 0.24), or hypoesthesia (10% vs 23%, p = 0.09). Full-thickness wound disruption was encountered in 9 patients (15%) in the modified Limberg group vs no patient in the modified Karydakis group (p = 0.003). The median follow-up duration was 20.5 months in each study group. One patient (2%) in the modified Karydakis group developed recurrent disease vs 2 patients (3%) in the modified Limberg group (p > 0.99). In the modified Karydakis group, 58 patients (97%) were satisfied with the cosmetic outcome and were willing to recommend the operation to others vs 43 patients (72%) in the modified Limberg group (p < 0.001). CONCLUSIONS: Both techniques provide effective treatment for pilonidal sinus disease and can be performed safely as day-case surgery. The modified Karydakis flap is associated with significantly shorter operative time, a lower full-thickness wound disruption rate, and a higher patient satisfaction rate.

Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma.

BACKGROUND: Traditionally, left-sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. Total abdominal colectomy is a one-stage procedure that will remove synchronous proximal neoplasms, reduce the risk of subsequent metachronous tumor, and avoid stoma. Colorectal stents are being used for palliation and as a bridge to surgery in obstructing colorectal carcinoma, making elective surgery straightforward, enabling easily mobilization and resection of the colon with a possible trend toward reduction in postoperative complication rates compared to emergency surgery. The purpose of this work was to compare the procedures of endoscopic stenting followed by elective colectomy versus total abdominal colectomy and ileorectal anastomosis in the management of acute obstructed carcinoma of the left colon as regards feasibility, safety, and clinical outcomes METHODS: From January 2009 through May 2012, 60 patients were randomized to either emergency stenting followed by elective resection (ESER group) or total abdominal colectomy and ileorectal anastomosis (TACIR group). RESULTS: Twenty nine patients (96.7 %) had successful stenting and underwent elective surgery 7-10 days later (ESER group). Postoperative complications were encountered in four patients in the ESER group compared to 15 patients in the TACIR group (p = 0.012). Anastomotic leakage was encountered in one patient (3.3 %) in the TACIR group. There were no operative mortalities in the present study. Within the first three postoperative months, the TACIR group patients had significantly more frequent bowel motions per day compared to the ESER group patients although (p = 0.013). In both study groups, the follow-up duration ranged from 6 to 40 months with a median of 18 months. Recurrent disease was encountered in five patients (17.2 %) in the ESER group compared to four patients (13.3 %) in the TACIR group (p = 0.228). CONCLUSION: Both techniques are feasible, safe, and produce comparable oncological outcomes. However, endoscopic stenting followed by elective resection was associated with significantly less postoperative complications and bowel motions per day.

Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study.

BACKGROUND: The aim of this study was to compare the surgical outcome of day-case laparoscopic cholecystectomy (DCLC) performed with the patient under spinal anesthesia with that performed with the patients under general anesthesia in the management of symptomatic uncomplicated gallstone disease. PATIENTS AND METHODS: One hundred eighty patients were prospectively randomized to either the spinal anesthesia DCLC group (SA-DCLC group) or the general anesthesia DCLC group (GA-DCLC group). Intraoperative events related to spinal anesthesia, postoperative complications, and pain scores were recorded. The incidences of both overnight stay and readmissions were also recorded. Patient satisfaction values as to the anesthetic technique and same-day discharge were assessed by direct questionnaire at the end of the first postoperative week. RESULTS: In both groups, all procedures were completed laparoscopically. In the SA-DCLC group, there were 4 (4.4%) anesthetic conversions due to intolerable right shoulder pain, and those 4 patients were excluded from further analysis. In the SA-DCLC group, all patients were discharged on the same day. Overnight stay was required in 8 patients (8.9%) in the GA-DCLC group (P<.001). The cause of overnight stay was nausea and vomiting in 4 patients (4.4%), inadequate pain control in 3 patients (3.3%), and unexplained hypotension in 1 patient (1.1%). Readmission was required in 1 patient (1.1%) in the GA-DCLC group. The difference in patient satisfaction scores with regard to both anesthetic technique and same-day discharge was not statistically significant between the two groups studied. CONCLUSIONS: DCLC performed with the patient under spinal anesthesia is feasible and safe and is associated with less postoperative pain and lower incidence of postoperative nausea and vomiting and therefore a lower incidence of overnight stay compared with that performed with the patient under general anesthesia.

Is monopolar electrocautery safe and effective for control of the cystic artery during laparoscopic cholecystectomy?

BACKGROUND: Laparoscopic cholecystectomy is one of the most common surgical procedures. Here we report our experience with the use of monopolar electrocautery to control the cystic artery during laparoscopic cholecystectomy. SUBJECTS AND METHODS: Data regarding the site, number, size, and method of control of the cystic artery during laparoscopic cholecystectomy were prospectively collected. Other data collected included the operative time, intraoperative difficulties, and postoperative complications. RESULTS: The study included 158 laparoscopic cholecystectomies. Two arteries were controlled in 25 patients (15.8%) and one artery in 122 patients (77.2%), while the cystic artery was not identified in 11 patients (7%). The artery was graded as small, medium, and large in 43, 72, and 32 patients, respectively. Patients with unidentified cystic artery were excluded from our data analysis. The artery was controlled using monopolar electrocautery in 114 patients (77.5%) and by metal clips in 33 patients (22.5%). The cystic artery was controlled lateral to the cystic lymph node in the majority of patients (68%). Neither bleeding nor bile duct injury was encountered throughout the study period. CONCLUSIONS: Electrocautery is safe and effective for control of the cystic artery during laparoscopic cholecystectomy. A future randomized study is needed to confirm the findings of the present study.

Diathermy excisional hemorrhoidectomy: a prospective randomized study comparing pedicle ligation and pedicle coagulation.

BACKGROUND: In hemorrhoidectomy, pedicle coagulation has been claimed to be associated with less postoperative pain compared with pedicle ligation. OBJECTIVE: This study was designed to compare the effects of pedicle ligation vs pedicle coagulation on postoperative pain in patients undergoing diathermy excisional hemorrhoidectomy. DESIGN: The study was conducted as a single-blind prospective randomized clinical trial. SETTING: Patients were treated at a single tertiary-level teaching hospital (Main University Hospital) in Alexandria, Egypt, from February 2009 to October 2010. PATIENTS: Patients with symptomatic grade III or IV hemorrhoids were eligible. INTERVENTION: Patients were randomly allocated to receive either pedicle coagulation or pedicle ligation during 3-quadrant diathermy excision hemorrhoidectomy. MAIN OUTCOME MEASURES: Patients reported postoperative pain daily on a visual analog scale (0-10, with 10 corresponding to the most severe pain) during the first 10 postoperative days. On-demand parenteral analgesic requirements were recorded during the first 24 hours after surgery. Operative time, postoperative complications, and wound healing rates at 6 weeks postoperatively were also recorded. LIMITATIONS: No a priori power calculation could be performed, so it was not possible to tell whether nonsignificant differences were real or a result of chance. RESULTS: A total of 136 patients were randomly assigned, and 120 patients completed the study (60 in each group). The overall median pain score for the first 10 postoperative days was significantly lower in the pedicle coagulation group than in the pedicle ligation group (4.65 vs 6.56, P < .001), and daily median pain scores were significantly lower for pedicle coagulation than for pedicle ligation throughout the first 6 postoperative days (P < .001). Postoperative pain scores followed different courses in the 2 groups. In the coagulation group, pain levels were lowest during the first 3 postoperative days, increasing from day 4 and then falling after day 8. In the ligation group, pain levels were highest during the first 4 postoperative days, then gradually decreased. The median number of analgesic ampoules required during the first 24 hours was also significantly lower for pedicle coagulation than for ligation: 1 (range, 0-3) vs 3 (range, 1-3); P < .001). The median operative time was 15 (range, 14-20) minutes with coagulation and 14.5 (range, 12-18) minutes with ligation (P < .001). No significant differences were observed in the incidence of postoperative complications or wound healing rates at 6 weeks postoperatively. No anal stenoses or recurrences were observed. CONCLUSIONS: Pedicle coagulation is safe and provides a superior alternative to pedicle ligation by decreasing postoperative pain in the first 6 postoperative days, as well as reducing parenteral analgesic requirements during the first 24 hours postoperatively.

Laparoscopic cholecystectomy in cirrhotics: a prospective randomized study comparing the conventional diathermy and the harmonic scalpel for gallbladder dissection.

BACKGROUND: Ultrasonically activated devices have been used for gallbladder dissection in laparoscopic cholecystectomy (LC) with encouraging results. The aim of the present study was to compare the surgical outcome of LC performed by the harmonic shears to that performed by the conventional diathermy in patients with cirrhosis. METHODS: In this prospective randomized study, 40 cirrhotic Child-Pugh's classes A and B patients with symptomatic uncomplicated gallstones disease were randomly assigned to either the Harmonic scalpel LC group (20 patients) or the conventional diathermy LC group (20 patients). RESULTS: The use of the harmonic shears was associated with a statistically significant shorter median operative time (55 vs. 82.5 minutes, P = .000), less median estimated intraoperative blood loss (50 vs. 120 mL, P = .000), and lower incidence of gallbladder perforation (10% vs. 70%, P = .000). In the Harmonic scalpel LC group, Laparoscopic subtotal cholecystectomy was resorted to in eight patients (40%) compared with six patients (30%) in the conventional diathermy LC group. No statistically significant difference was found between both groups as regards the conversion rate, the median hospital stay, and the incidence of postoperative complications. Neither bile leaks nor Bile duct injuries were encountered in either group. Similarly, no mortalities were encountered in the present study. CONCLUSIONS: The Harmonic shears achieved complete hemobiliary stasis. Further, it provided a superior alternative to the conventional diathermy in terms of shorter operative time, less intraoperative blood loss, and lower incidence of gallbladder perforation partly through facilitating the performance of laparoscopic subtotal cholecystectomy.

Laparoscopic cholecystectomy under spinal versus general anesthesia: a prospective, randomized study.

BACKGROUND: For laparoscopic cholecystectomy (LC), the use of spinal anesthesia may offer several advantages over general anesthesia. The aim of this prospective, randomized study was to compare the surgical outcome of LC performed under general anesthesia to that of LC performed under spinal anesthesia. METHODS: Sixty patients were randomly assigned to either the SALC (spinal anesthesia LC group, 30 patients) or GALC group (general anesthesia LC group, 30 patients). Intraoperative events related to spinal anesthesia, postoperative complications, and pain scores were recorded. Patient satisfaction as to the anesthetic technique received was assessed 2 weeks postoperatively by direct patient questionnaire. RESULTS: In both groups, all procedures were completed laparoscopically. In the SALC group, all procedures were completed under spinal anesthesia and there were no anesthetic conversions. There was no statistically significant difference in the mean operative time between both groups. For the first 2 and 4 hours postoperatively, the mean pain score of the SALC group was statistically significantly lower than that of the GALC group. For the first 24 hours postoperatively, the mean number of analgesic ampoules/patient was statistically significantly lower in the SALC group. In the SALC group, 28 patients (93.3%) considered the technique "very well," compared with 30 patients (100%) in the GALC group. The difference in the overall patient satisfaction scores between both studied groups was not statistically significant. CONCLUSIONS: LC performed under spinal anesthesia is feasible, safe, and is associated with significantly less early postoperative pain, compared to that performed under general anesthesia.

Laparoscopic-assisted truncal vagotomy and gastro-jejunostomy: trial of simplification.

BACKGROUND: Truncal vagotomy and gastro-jejunostomy is an effective procedure for Gastric Outlet Obstruction. The authors' experience with the procedure is presented and an alternative technique for creating the gastro-jejunostomy is described. METHODS: From January 2005 through June 2007, 18 patients with gastric outlet obstruction secondary to a cicatrizing peptic duodenal ulcer underwent laparoscopic truncal vagotomy and an ante-colic laparoscopic-assisted stapled gastro-jejunostomy. RESULTS: All procedures were completed laparoscopically with a mean operative time of 81.2 +/- 11.1 minutes. Anastomotic leak was encountered in 1 (5.5%) patient and bile vomiting in 2 patients (11%). The mean follow-up duration was 22.8 +/- 9.8 months. None of the patients developed recurrent obstruction. CONCLUSIONS: The procedure is feasible, safe, and provides an effective cure for gastric outlet obstruction. The laparoscopic-assisted stapled gastro-jejunostomy reduces the operative time and may reduce the cost of the procedure.

Evaluation of the Novel Monoclonal Antibody Against DOG1 as a Diagnostic Marker for Gastrointestinal Stromal Tumors.

BACKGROUND AND OBJECTIVES: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. With the growing effectiveness and availability of first and second-generation tyrosine kinase inhibitor (TKI) drugs, the accurate diagnosis of GIST has become imperative. The problem is that some GISTs with KIT or Alpha-type platelet-derived growth factor receptor (PDGFRA) mutations may have low KIT expression by immunohistochemistry yet will still benefit from TKI drugs. Molecular analysis is a costly and laborious process. Therefore the emergence of a new sensitive immunohistochemical marker for GISTs would be ideal. Recently antibodies against "Discovered on GIST-1" (DOG1) have been generated. The aim of this study was to evaluate the monoclonal DOG1.1 antibody as a diagnostic marker for GISTs and to compare immunohistochemical staining and diagnostic efficacy of DOG1.1 with that of KIT in GISTs. MATERIALS AND METHODS: Forty seven paraffinembedded GISTs were immunostained with both KIT and DOG1.1 antibodies. Immunoreactivity was graded semiquantitatively from 0 to 4. Some other mesenchymal tumors were included in the study and stained for both markers to test for their specificity. RESULTS: Out of the 47 GISTs, 44 were immunoreactive for both KIT and DOG1.1 antibodies (93.62%). Two cases (4.25%) were KIT-positive DOG-negative and the remaining case was DOG-positive KIT-negative (2.13%). A statistically significant concordance was found between KIT and DOG1.1 immunoreactivity (p=0.004), with moderate agreement between immunostaining scores (kappa =0.379). As regards tumor site, a statistically significant association was found between high DOG1.1 scores and gastric GIST (p=0.008). High KIT and DOG1.1 immunostaining scores were significantly associated with highrisk tumors (p=0.002 and p=0.002 respectively). DOG1.1 immunoreactivity was focal in more than half of the cases. The overall diagnostic accuracy of DOG1.1 was 96.5%, with a specificity and sensitivity of 100% and 95.7%, respectively. The overall positive predictive values and negative predictive values were 100% and 84.6%, respectively. As for KIT, The overall diagnostic accuracy was 94.8%, with a specificity and sensitivity of 81.8% and 97.8%, respectively. The overall positive predictive values and negative predictive values were 95.8% and 90%, respectively. CONCLUSIONS: This study has demonstrated that DOG1.1 is a more specific marker for GIST than KIT, yet its sensitivity is a little inferior to that of KIT owing possibly to the focal staining of DOG1 antibody in many cases. In conclusion, in our institution, in which cost effective health care is a priority, we recommend using DOG1 as the first choice antibody for the diagnosis of GIST as it is a more specific marker. If it is negative, then KIT is tried. If this latter is also negative, then several other antibodies should be tested. And owing to the potential therapeutic significance of GIST diagnosis, if still the results of immunohistochemistry are ambiguous, mutational analysis should be considered to confirm the diagnosis. KEY WORDS: GIST - DOG1 - KIT - Immunohistochemistry.

Clipless laparoscopic cholecystectomy by ultrasonic dissection.

BACKGROUND: Ultrasonically activated devices have been used in gallbladder dissection in the laparoscopic cholecystectomy with encouraging results. The aim of this study was to compare between the safety and efficacy of the harmonic shears and the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy. METHODS: In this prospective study, 120 patients with symptomatic gallstone disease were randomly assigned to either the harmonic scalpel laparoscopic cholecystectomy group (HS group=60 patients) where closure and division of the cystic duct was achieved solely by the harmonic shears or the clip and cautery laparoscopic cholecystectomy group (C&C group=60 patients). RESULTS: Neither minor nor major bile leaks were encountered in either group. Similarly, no bile-duct injuries were encountered in the present study. The incidence of gallbladder perforation was statistically significantly higher in the C&C group, compared to the HS group (30 vs. 10%, respectively; P=0.002). The median operative time was statistically significantly shorter in the HS group than in the C&C group (32 vs. 40 minutes, respectively; P=0.000). No statistically significant difference was found in the incidence of postoperative complications between both groups. CONCLUSIONS: The harmonic shears are as safe and effective as the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy. Further, it provides a superior alternative to the currently used high-frequency monopolar technology in terms of shorter operative time and lower incidence of gallbladder perforation.

Ligasure vs. conventional diathermy in excisional hemorrhoidectomy: a prospective, randomized study.

PURPOSE: This study was designed to compare the surgical outcomes of hemorrhoidectomy performed by the Ligasure with that performed by the conventional diathermy. METHODS: A total of 110 patients were randomized to Ligasure (55 patients) or diathermy (55 patients) hemorrhoidectomy. The operative time, postoperative pain scores, parenteral analgesic requirements in the first 24 hours, postoperative complications, and wound healing rates at six weeks postoperatively were documented. RESULTS: The median operative time was 8 (range, 7-10) minutes for the Ligasure group and 18 (range, 15-21) minutes for the diathermy group (P < 0.001). Throughout the first postoperative week, the daily median pain score was lower in the Ligasure group than in the diathermy group (P < 0.001). The median number of analgesic ampoules during the first 24 hours postoperatively was lower in the Ligasure group (P < 0.001). There was no statistically significant difference in the incidence of postoperative complications. At six weeks postoperatively, more patients in the Ligasure group had complete healing of wounds (P = 0). CONCLUSION: Ligasure provides a superior alternative to conventional diathermy in hemorrhoidectomy by reducing the operative time, postoperative pain, parenteral analgesic requirements during the first 24 hours postoperatively, and the time to complete healing of wounds.

Results of the lateral advancing flap operation (modified Karydakis procedure) for the management of pilonidal sinus disease.

PURPOSE: The Karydakis procedure is one of the asymmetric flap techniques used in the treatment of sacrococcygeal pilonidal sinus disease. The procedure consists of an asymmetrical elliptical excision, mobilization of the flap from the median side of the wound, fixation of the base of the flap to the sacrococcygeal fascia, and suturing of its edge to the lateral one. A modification of the original technique consisting of unfixing the base of the flap to the sacrococcygeal fascia with the purpose of flattening the natal cleft has been applied and its results evaluated. METHODS: The present study included 82 consecutive patients. Data concerning age, gender, body mass index, duration of complaint, findings at presentation, and previous surgical treatment were obtained. The modified technique was applied in all patients. The postoperative complications and hospital stay were recorded. Patients were followed up by physical examination to detect recurrence. RESULTS: The hospital stay was two days for all patients. Postoperative complications were encountered in six patients (7.3 percent). Wound infection was encountered in four patients (4.9 percent), and subcutaneous fluid collections were encountered in two patients (2.4 percent). No recurrences were encountered throughout the 20 +/- 6.8 months mean follow-up duration. CONCLUSIONS: The low complication rate, short hospital stay, short healing time, high degree of patient satisfaction, and absence of recurrence render the present modified technique a viable option in the management of sacrococcygeal pilonidal sinus disease.

Rectal carcinoma in Egyptian patients less than 40 years of age.

In Egypt, there is an increasing incidence of colorectal cancer, especially among patients < or = 40 years of age. The aim of this work was to study the characteristics of rectal cancer in a group of young Egyptian patients treated at Alexandria Main University hospital, Alexandria, Egypt, from June 1998 to June 2001. This study included 50 rectal cancer patients. They were divided into two groups. Group I was patients < 40 years of age (26 patients), and group II was patients > 40 years of age (24 patients). Both groups were evaluated regarding history taking and physical examination, the gross tumor characteristics, the presence or absence of metastases, the histopathological characteristics of the tumor, and the treatment failure within the 3-year period of this study. Group I patients had a significantly longer duration of complaint. A total of 15.4% of patients in this group presented with intestinal obstruction compared with 8.3% in group II. A total of 30.8% of patients in group I presented with metastatic disease compared with 20.8% in group II. More patients in group I had fixed and/or circumferential lesions than did those of group II (38.5% and 53.8% versus 20.8% and 8.3%, respectively). More patients in group I had nonresectable tumors. A total of 62.5% of group II patients underwent curative resection compared with 53.8% of the patients in group I. A total of 38.5% of patients in group I had mucoid carcinoma compared with 8.3% in group II. At the end of the 3-year period of this study, only 38.5% of group I patients were alive and free of disease compared with 45.8% in group II. In Egypt, rectal cancer patients <40 years of age have more advanced disease at presentation and a higher incidence of treatment failure caused by both a delay in the diagnosis and a more aggressive pattern of the disease.