Laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer: initial Egyptian experience at the National Cancer Institute.

BACKGROUND: Laparoscopic gastrectomy has been used as a superior alternative to open gastrectomy for the treatment of early gastric cancer. However, the application of laparoscopic D2 lymphadenectomy remains controversial. This study aimed to evaluate the feasibility and outcomes of laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer. RESULTS: Between May 2016 and May 2018, twenty-five consecutive patients with gastric cancer underwent laparoscopic D2 gastrectomy: eighteen patients (72%) underwent distal gastrectomy, four patients (16%) underwent total gastrectomy, and three patients (12%) underwent proximal gastrectomy. The median number of lymph nodes retrieved was 18 (5-35). A positive proximal margin was detected in 2 patients (8%). The median operative time and amount of blood loss were 240 min (200-330) and 250 ml (200-450), respectively. Conversion to an open procedure was performed in seven patients (28%). The median hospital stay period was 8 days (6-30), and the median time to start oral fluids was 4 days (3-30). Postoperative complications were detected in 4 patients (16%). There were two cases of mortality (8%) in the postoperative period, and two patients required reoperation (8%). CONCLUSIONS: Laparoscopic gastrectomy with D2 lymphadenectomy can be carried out safely and in accordance with oncologic principles.

Hyperthermic Intraperitoneal Chemotherapy as a Treatment for Epithelial Ovarian Cancer.

Treatment by cytoreductive surgery (CRS) and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) has been an option for selected patients with peritoneal carcinomatosis. This study aims to evaluate the impact of HIPEC in epithelial ovarian cancer (EOC). A retrospective observational cohort study including 48 EOC patients treated and followed up between 2012 and 2016. Thirty-seven cases were treated by CRS only, while 11 cases were treated by CRS and HIPEC. The study was performed at National Cancer Institute (NCI)-Cairo University. There was no statistically significant difference regarding overall survival or disease-free survival between the group of EOC patients treated by CRS only and the one treated by CRS and HIPEC. Presence of ascites and histological types (serous/non-serous) were the significant independent variables related to overall survival. Presence of ascites was the only independent variable associated with a significant relation to disease-free survival. No statistically significant impact of HIPEC in treatment of EOC was found in this study.

Combined cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as a treatment for recurrent epithelial ovarian cancer-National Cancer Institute experience.

BACKGROUND: Complete cytoreduction has been associated with survival benefit in the treatment of recurrent epithelial ovarian cancer (EOC). In this study, the aim is to investigate the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of recurrent EOC. PATIENTS AND METHODS: This is a descriptive (case series) study including 9 patients with recurrent EOC treated by CRS and HIPEC. They were treated and followed up between December 2011 and December 2017. The study was performed at The National Cancer Institute (NCI) - Cairo University (CU). RESULTS: Postoperative death occurred in 2 cases, while recurrence occurred in one case. Six cases had smooth postoperative course and free follow-up. Median follow-up period was 39 months, ranging from 29 to 47 months. Median overall survival was 42 months while median disease-free survival was not reached. CONCLUSIONS: Treatment of recurrent EOC by CRS and HIPEC appears to be promising. However, this line of treatment requires further evaluations and larger studies for better assessment of the potential survival benefits and possible complications.

Peritoneal carcinomatosis in colorectal cancer: Defining predictive factors for successful cytoreductive surgery and hyperthermic intraperitoneal chemotherapy - A pilot study.

BACKGROUND: Peritoneal carcinomatosis originating from colorectal cancer (PC-CRC) carries a dismal prognosis. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) have been offered to those patients with substantial health and economic burden, nevertheless not all patients are fitting this treatment modality and outcome is generally still poor. OBJECTIVE: To elicit predictive factors associated with the success of CRS and HIPEC in PC-CRC patients. PATIENTS AND METHODS: This is a pilot study including 30 consecutive patients with PC-CRC; 20 of them (66.7%) presented with metachronous peritoneal disease. All patients were planned for CRS and HIPEC with Mitomycin-C after receiving preoperative systemic chemotherapy for 3 months. RESULTS: On exploration, CRS and HIPEC were successful in 17 patients (56.6%) who had completeness of cytoreduction score 0-1 (CC-0/1), whereas failure (CC-2) was encountered in 13 patients (43.3%). The presence of ascites, extensive peritoneal disease (PCI > 20) was significantly correlated with failure to achieve CRS and HIPEC (p < 0.001); also, the primary rectal site showed a trend towards significance (p = 0.08). The cumulative overall survival (OS) and progression-free survival (PFS) at 2 years were 66.6 and 62.6%, respectively. Patients who achieved CC-0/1 had significantly prolonged OS compared to CC-2 (p < 0.001). On multivariate analysis, the CC score and the original site were independent prognostic factors for OS (p = 0.04 and 0.02, respectively). CONCLUSION: In patients with PC-CRC, malignant ascites and PCI > 20 are poor prognostic factors associated with failure to accomplish CRS with consequent poor survival.

First experience of the Egyptian National Cancer Institute using the robot-assisted laparoscopic approach in radical hysterectomies for cervical cancer.

AIM OF WORK: Robotics in surgery led to an improvement of visualization, a better handling of tissues and better suturing. This study aimed to document the first experience of the Egyptian National Cancer Institute (NCI) using the robot-assisted laparoscopic approach in radical hysterectomies for cervical cancer and to highlight observed advantages, disadvantages, morbidity and oncological outcomes. PATIENTS AND METHODS: Data of cases that had either early cervical cancer (stage IB-IIA1 with a tumor ≥2 cm) or locally advanced cervical cancer (Stage IIA2-IIB after chemo-radiotherapy) were collected prospectively. Study patients underwent robotic radical hysterectomies for their cervical cancers at the NCI, Cairo University, between January 1, 2015 and December 31, 2016. For each patient, duration of surgery, amount of blood loss, and intra-operative complications were recorded. Similarly, the duration of postoperative hospital-stay, analgesia used and post-operative gastrointestinal recovery were documented. Pathological assessment of safety margins and the lymph nodes number yield were also assessed. RESULTS: Twenty patients underwent robotic radical hysterectomy during the study period. Twelve cases had early cervical cancer while 8 suffered locally advanced disease. The mean procedure time was 319 (range 240-560) minutes; the mean blood loss was 309 (range 150-600) ml. Three cases had bladder injuries during their procedures. The median hospital stay was 6 (range 4-10) days. One case had a positive margin. The median of lymph nodes yield number was 15 (range 10-25). Follow-up ranged 9-31 months, with only one case developing local recurrence. CONCLUSION: Robotic radical hysterectomy is a feasible approach with a tolerable rate of complications.

Toward standardization of laparoscopic resection for colorectal cancer in developing countries: A step by step module.

BACKGROUND: Despite the proven benefits, laparoscopic colorectal surgery is still underutilized among surgeons especially in developing countries. Also a steep learning is one of the causes of its limited adoption. OBJECTIVE: To explore the learning curve of single surgeon experience in laparoscopic colectomy and feasibility of implementing a well standardized step by step operative technique to overcome the beginning technical obstacles. PATIENTS AND METHODS: This prospective study included 50 patients with carcinoma of the left colon and rectum recruited from the department of surgical oncology at National Cancer Institute, Cairo University in the period 2012-2016. All the procedures were performed through laparoscopic approach. Intra and post-operative data were recorded and analyzed. RESULTS: The mean age was 49.7±10.6years (range: 33-74years). They were 29 males and 21 females. The mean operation time was 180min (range 100-370min), and the mean blood loss was 350ml (60-600ml). Six patients (12%) were converted to a laparotomy. The median lymph nodes harvest was 12 (range 7-25). The mean time of passing flatus after surgery was 2days (1-4days) and the mean time of passing stools was 3.3days (2-5) days. The median hospitalization period after surgery was 4days (3-12). 5 patients (10%) had postoperative morbidity, major morbidity occurred in one patient. CONCLUSION: Laparoscopic colorectal surgery for colorectal cancer is safe and oncologically sound, standardized well-structured laparoscopic technique masters the procedure even in early learning curve setting.

The profile of extremity and trunk soft tissue sarcoma in a tertiary referral center.

BACKGROUND: Proper surgery with adequate safety margin and adjuvant radiotherapy is the main line of treatment of extremity and trunk soft tissue sarcoma (STS). In spite of improved management, the long term follow up is still not satisfactory. OBJECTIVE: To evaluate long term outcome of STS of extremities and trunk regarding adequacy of resection, recurrence and survival. PATIENTS AND METHODS: This prospective study included 25 patients with STS involving extremity and trunk. All patients were treated with wide radical excision and had adjuvant irradiation and followed up for a median of 26months. RESULTS: The mean age was 40.0±15.3years. They were 16 males and 9 females. Eight patients (32%) had positive or close surgical margins. The median overall survival (OS) was 26.5months. In univariate analysis, lower limb tumors, stage III and grade 3 were significantly associated with worse overall survival (OS) (p=0.007, 0.02, and 0.020, respectively) and disease free survival (DFS) (p=0.005, 0.001, and 0.001, respectively). On multivariate analysis the only independent factor that affects the OS and DFS was the stage (p value=0.029, Hazard ratio: 3.64, 95% confidence interval: 1.14-11.61 and p value=0.003, Hazard ratio: 5.75, 95% confidence interval: 1.82-18.18 respectively). CONCLUSION: Despite adequate surgery and adjuvant irradiation, 5years follow up results of treatment of extremity and trunk soft tissue sarcoma is still poor. This highlights the importance of early detection of small STS in extremity and trunk.

Outcome and surgical strategy in critical sites in cases of psuedomyxoma peritonei.

BACKGROUND: For a long time peritoneal neoplasms were considered beyond surgical intervention and beyond cure, till the concept of cytoreductive surgery (CRS) and adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) was introduced. However this surgical intervention is technically demanding and associated with considerable postoperative morbidity. OBJECTIVE: To describe the surgical strategy in resection of critical sites loaded by heavy tumor deposits and to evaluate short and long term results of CRS and HIPEC, in a cohort of Egyptian patients with pseudomyxoma peritonei (PMP) from appendiceal origin. PATIENTS AND METHODS: 21 patients with PMP, age ranged from 40 to 63years, 12 males and 9 females. All were recruited from the department of surgery at the National Cancer Institute (NCI), Cairo University over the period from February 2011 to February 2016. They were subjected to CRS and HIPEC with mitomycin-C. RESULTS: The median peritoneal carcinoma index (PCI) was 22 (range: 10-39). Optimal cytoreduction (CCR-0/1) was achieved in 19 patients (90.4%) of whom 17 patients (80.9%) had a complete cytoreduction (CCR-0). The median follow up period was 51.5months (range: 0.07-82.3months). The cumulative overall survival was 85.7% while the cumulative disease free survival was 76.9%. CONCLUSION: To the best of our knowledge, this is the first study reporting five years postoperative outcome of CRS and HIPEC in Egyptian patients with PMP from appendiceal origin. Our results support that although technically demanding this treatment modality is safe and associated with favorable outcome.

Preliminary results of robotic colorectal surgery at the National Cancer Institute, Cairo University.

BACKGROUND: The available literature on minimally invasive colorectal cancer demonstrates that laparoscopic approach is feasible and associated with better short term outcomes than open surgery while maintaining equivalent oncologic safety. Reports have shown that robotic surgery may overcome some of the pitfalls of laparoscopic intervention. OBJECTIVE OF THE WORK: To evaluate early results of robotic colorectal surgery, in a cohort of Egyptian patients, regarding operative time, operative and early post-operative complications, hospital stay and pathological results. PATIENTS AND METHODS: A case series study which was carried out in surgical department at National Cancer Institute, Cairo University. Ten Egyptian cases of colorectal cancer (age ranged from 30 to 67, 5 males and 5 females) were recruited from the period of April 2013 to April 2014. Robotic surgery was performed to all cases. RESULTS: Three patients had low anterior resection, three anterior resection, one total proctectomy, one abdominoperineal resection, one left hemicolectomy and one colostomy. The study reported no mortalities and two morbidities. The mean operative time was 333min. The conversion to open was done in only one patient. A total mesorectal excision with negative circumferential margin was accomplished in all patients, distal margin was positive in one patient. Mean lymph nodes removed was 10.7. Mean hospital stay was 7.4days. CONCLUSION: To the best of our knowledge, this is the first study reporting the outcomes of robotic colorectal cancer intervention in Egyptian patients. Our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles.

Effect of dexmedetomidine and cold stress in a rat model of neuropathic pain: Role of interleukin-6 and tumor necrosis factor-α.

Dexmedetomidine (Dex) is a novel Alpha 2-adrenoceptor agonist. It decreases sympathetic tone and attenuates the stress responses to anesthesia and surgery. People exposed to cold suffer unpleasant thermal pain, which is experienced as stress and causes the release of noradrenaline from the sympathetic terminals. The present study investigated the effects of cold stress and dexmedetomidine on chronic constriction injury (CCI) model of the sciatic nerve in rats. Sixty four male Wistar rats were divided into seven groups of eight rats each: repeated cold stress (RCS) group, sham RCS group, CCI group, sham CCI group, Dex-treated group received a single dose of Dex (5 µg/kg), CCI+Dex group, CCI+RCS group. Interleukin-6 (IL-6) and tumor necrosis factor- alpha (TNF-α) levels in the serum were measured by enzyme-linked immunosorbent assay. The mean body weight of CCI, RCS, CCI+RCS, CCI+Dex and RCS+Dex groups decreased significantly compared with pre-values. Dexmedetomidine and CCI caused significant changes of the systolic, diastolic and mean blood pressure. Both RCS and CCI groups showed significant decreased of reaction time in the hot plate test. The RCS and CCI groups demonstrated a significant mechanical hyperalgesia, while pain threshold was increased in the RCS+Dex group. A significant decrease of serum IL-6 and TNF-α was demonstrated in CCI+RCS and CCI+Dex groups. The therapeutic effectiveness of dexmedetomidine in neuropathic pain may be through inhibition of proinflammatory cytokines, primarily IL-6 and TNF-α. Moreover, cold stress may result in increased resistance to neuropathic pain.

Laparoscopy with laparoscopic ultrasound for pretreatment staging of hepatic focal lesions: a prospective study.

INTRODUCTION: The need for accurate intrahepatic staging is crucial for patients with primary or secondary hepatic malignancies. Currently available data indicate that laparoscopy with laparoscopic ultrasound provides information similar to that obtained by intraoperative ultrasound and that it is able to identify small intrahepatic lesions not diagnosed by preoperative conventional imaging techniques. OBJECTIVE: To determine the role of preoperative laparoscopy and laparoscopic ultrasonography in patients with potentially resectable hepatic focal lesion or candidate for radiofrequency ablation based on preoperative imaging. MATERIAL AND METHODS: From March 2004 to March 2007, 55 patients with potentially resectable hepatic focal lesions were candidates for exploratory laparotomy based on preoperative abdominal ultrasonography and triphasic spiral CT. All cases were then reevaluated prior to surgery using laparoscopy and laparoscopic ultrasound. All these procedures were performed within a time period of no more than 4 weeks. The data obtained were compared to those obtained by the preoperative conventional imaging studies as regards the presence of satellites, subcentimetric lesions, newly discovered deep parynchymatous lesions, liver condition, portal vein thrombosis, nodal metastases, ascites, peritoneal implants, size and site of the primary lesion. RESULTS: After performing ultrasound-guided laparoscopy, fourteen patients proved to be unfit for surgical resection or ablation, seven patients showed newly discovered focal lesions, five patients proved to have satellites around the tumor and peritoneal deposits, one patient had ascites and one patient had been falsely diagnosed as HCC, proved to have had a liver abscess. CONCLUSION: Preoperative laparoscopy and laparoscopic ultrasonography as an adjunct to preoperative imaging techniques provide more accurate staging for patients with potentially resectable hepatic focal lesions.