Surgery

Emergency versus delayed laparoscopic cholecystectomy for acute cholecystitis Ahmed Salah Arafa, Mostafa Mohamed Khairy, Mohamed Farouk Amin The Egyptian Journal of Surgery 2019 38(2):171-179 Background Acute cholecystitis (AC) is a major complication of gallstones. Laparoscopic cholecystectomy for AC has still not become routine because the timing and approach to the surgical management in patients with AC is still a matter of debate among general surgeons. The aim of this investigation is to clarify the safety and feasibility of the emergency or early laparoscopic cholecystectomy (ELC) for AC in comparison with the interval or delayed laparoscopic cholecystectomy (DLC) regarding procedure safety, operating time, injury to bile ducts, postoperative pain, total length of hospital stay, cost factor, loss of active days of work (days away from work), and conversions to open cholecystectomy. Patients and methods One hundred forty-eight patients were managed by laparoscopic cholecystectomy for AC and were randomized into two groups; the first (early) group (n=74) was managed by ELC and was carried out within 72 h of onset of symptoms, while the second (interval) group was managed by DLC and was carried out at least 6 weeks after symptoms settled. Clinical presentation, duration of symptoms, ultrasound findings, frequency of conversion to open operation, and numbers/types of complications were recorded. Moreover, the statistical analysis was carried out using the Statistical Package for Social Sciences. Results Our study claimed that ELC has a low conversion rate, shorter operative time, postoperative course, and significantly shorter total hospital stay (P<0.001) but longer operation time without an increase in morbidity to the patient. Conclusion Current evidence supports ELC as the preferred treatment strategy for patients presenting with AC. It allows a shorter hospital stay and greater patient satisfaction, but shares similar operative morbidity, mortality, and conversion rate as DLC.

Endovascular management of iliac vein compression syndrome: a prospective case series of 61 patients Ahmed K Gabr, Ahmed K Allam The Egyptian Journal of Surgery 2019 38(2):180-193 Context Iliac vein compression syndrome (IVCS) or May–Thurner syndrome is an anatomically variable condition of venous outflow obstruction caused by extrinsic compression. The pathology of this condition is secondary to a partial obstruction of the common iliac vein by an overlying common iliac artery with subsequent entrapment of the left common iliac vein. Clinical presentations include, but not limited to, pain, swelling, venous stasis ulcers, and skin discoloration. With extensive deep venous thrombosis, postphlebitic syndrome, with all its sequelae, may also develop. Endovascular interventions of this syndrome have become first-line therapy. Aims To estimate the prevalence of IVCS in patients with unilateral left lower limb venous disease [chronic venous disease (CVD)], assess the sensitivity and specificity of modified computed tomography venography in the diagnosis of IVCS, and evaluate the feasibility and effectiveness of the endovascular treatment. Settings and design This was a prospective case series study. The study was performed at three tertiary referral centers in Kingdom of Saudi Arabia (Security Forces Hospital Program, Al-Noor Specialist Hospital, Makkah, Almoosa Specialist Hospital, Al-Ahsaa) and three hospitals in Egypt (Benha University Hospitals, Nile Insurance Hospital, and Kuwaiti Specialized Hospital, Benha). Patients and methods Between March 2015 and February 2018, we evaluated 369 patients with unilateral left lower limb symptomatic CVD in the outpatient clinic of vascular surgery in the study hospitals. Sixty-one symptomatic patients with IVCS who received endovascular treatment were included in our study. Statistical analysis used The initial data entry used Microsoft excel (2010 version) for logical proofreading and analysis. We expressed continuous data as mean±SD and compared continuous variables using two-sided Student’s t tests. We estimated stent patency using Kaplan–Meier method. We considered P value less than 0.05 to be statistically significant. Statistical analysis was performed by using IBM Statistical Package for the Social Sciences software (version 22 for Windows program package). Results The 1-year patency rates in the nonthrombotic and thrombotic IVCS groups were 95.7 and 80%, respectively (P=0.146). The overall primary patency rate at 1 year after treatment was 93%. Complete pain relief was achieved in 76.7% of patients. The overall edema relief rate was 78.1%. Of the 12 limbs with active ulceration before treatment, 10 (83.3%) healed completely. Conclusion IVCS is not an uncommonly encountered condition, especially among patients with unilateral left lower extremity CVD. Computed tomography venography with three-dimensional reconstruction images was more sensitive and specific as a diagnostic approach for IVCS and provided useful information for the endovascular treatment planning. Moreover, endovascular therapy is feasible and effective for treating left-sided IVCS with high technical success rate and with an acceptable complication profile. So, we concluded that endovascular treatment should be considered as the first line of therapy for patients experiencing IVCS.

Feasibility of laparoscopic cholecystectomy in patients with previous upper abdominal surgery Tamer Nabil, Ahmed Hussein, Salah Soliman, El-Ashraf Thabet The Egyptian Journal of Surgery 2019 38(2):194-197 Background and aim There is still a considerable percentage of patients in whom laparoscopic cholecystectomy (LC) cannot be successfully performed and conversion to open surgery is required. The potential risks have dissuaded some surgeons from using the laparoscopic procedure in patients with symptomatic gallstones and previous upper abdominal surgery (UAS). The aim of this study is to investigate the impact of previous UAS on the successful performance of LC. Patients and methods Between September 2016 and September 2017, 50 patients with previous UAS and symptomatic cholelithiasis were subjected to LC. Intraoperative data regarding difficulties, duration of surgery, rate of conversion, and any incidental postoperative event were recorded. Results No mortality occurred. Adhesiolysis was not required in all cases. There were no complications directly attributable to adhesiolysis. Postoperative complications occurred in 12 (24%) patients. The procedure was completed laparoscopically in 44 patients with a 12% conversion rate. Conclusion Previous UAS is not a contraindication to safe LC, but is associated with an increased need for adhesiolysis, a longer operative time, an increased open conversion rate, and sometimes a larger number of trocars.

Comparative study between no touch technique and conventional method in the distal radio cephalic arterio venous fistula for hemodialysis Mahmoud S Eldesouky The Egyptian Journal of Surgery 2019 38(2):198-203 Background The distal radiocephalic arteriovenous fistula (RC-AVF) is the gold standard for hemodialysis but has significant failure rates owing to occlusions and failure to mature. The size and quality of the veins play an important role in the patency of the fistula. Objective The aim of this study was to evaluate the no-touch technique compared with the conventional method in the distal radiocephalic fistula for hemodialysis in terms of patency and complications. Patients and methods A prospective randomized study including 80 patients with ESRD in need for hemodialysis access was done between March 2016 and March 2017 and followed up to October 2017 at Menoufia university hospital. The patients were randomly categorized into two groups (no-touch group that included 40 patients where the vein and artery were dissected with the surrounding tissue cushion and conventional group that included 40 patients). Primary failure, primary and secondary patency rates, and complications of each group were collected and analyzed. Patients with vein caliber less than 2.5 mm, previous arteriovenous fistula, without venous continuity in the arm, or with severely atherosclerotic radial artery were excluded from the study. Results In the no-touch group, primary fistula failure was 7.5%, whereas three (7.5%) fistulas failed later one owing to thrombosis (one case), anastomotic pseudoaneurysm (one case), and anastomotic stenosis (one case). Primary and secondary patency rates at 6 months were 85 and 90%, respectively, whereas in the conventional group, primary fistula failure was 17.5%, whereas eight (20%) fistulas failed later owing to thrombosis (two cases), anastomotic pseudoaneurysm (two cases), anastomotic stenosis (three case), and venous hypertension (one case). Primary and secondary patency rates at 6 months were 62.5 and 67.5%, respectively Conclusion The results of this study indicate that no-touch technique can be used for primary radiocephalic fistula surgery with better patency rate and less complications compared with conventional method. This method offers the potential to create a RC-AVF in patients with distal cephalic veins 2.5 mm or more in caliber with encouraging results.

Drug-eluting balloon angioplasty versus bare-metal stent in treating chronic total occlusion of femoropopliteal arterial segment: a review of 1-year outcome of 90 patients with TASC C and D lesions Ahmed K Allam, Mohamed Ismail The Egyptian Journal of Surgery 2019 38(2):204-213 Background Bare-metal stent (BMS) scaffolding of superficial femoral artery occlusive lesions has been associated with high rates of late clinical failure. Maintaining the patency of recanalized arterial segments was the main issue behind the concept of leaving nothing behind to be evolved and percutaneous balloon angioplasty becomes the preferred option for endovascular therapy. Drug-eluting balloons (DEBs) have shown to be an effective alternative to BMS for patients with de novo complex superficial femoral occlusive disease. Aims The aim was to compare the outcome of DEB versus BMS in treating complex chronic total occlusion of superficial femoral and proximal popliteal artery in patients with disabling claudication and critical limb ischemia regarding technical success, primary patency, clinically driven target lesion revascularization (cd-TLR), and limb salvage rate. Materials and methods The current study is a multicenter, prospective, randomized study. Ninety patients (110 limbs) complaining of disabling and critical limb ischemia due to complex femoropopliteal occlusive lesions were randomly allocated into two groups according to the intervention method performed. Group A included 48 patients (57 limbs) who were submitted for treatment with paclitaxel DEBs and group B included 42 patients (53 limbs) submitted for treatment with BMS. The follow-up period was for 1, 6, and 12 months. Statistical analysis was performed by using the IBM SPSS Statistics version 22 for Windows Program Package (SPSS Inc., Chicago, IL, USA). Results BMSs seem to have lower patency and higher cd-TLR rates compared with patients who received paclitaxel drug-coated balloons but was not statistically significant. The primary patency rates were 100, 96, and 86.2% at 1, 6, and 12 months’ respectively’ in the DEB group versus 100, 89.8, and 77.6% at 1, 6, and 12 months, respectively, in the BMS group. Clinically driven TLR rates were 2 and 7.8% at 6 and 12 months, respectively, in the DEB group versus 6.1 and 14.2% at 6 and 12 months, respectively, in the BMS group. Conclusion Percutaneous therapy for Trans atlantic inter-societies consensus (TASC) C and D femoropopliteal lesion using DEB or BMS is safe and effective with a high patency rate of 1 year. Paclitaxel drug-eluting balloons seem to have a promising role in the prevention of restenosis and recurrence of peripheral arterial occlusive disease. However, stents are still playing important bailout role in the treatment of residual stenosis and dissection. Further follow-up is essential to obtain and document long-term outcome of different percutaneous therapy for complex and long superficial femoral artery (SFA) lesions.

The effect of laparoscopically assisted versus open resection of rectal cancer on short-term and pathological outcomes: a randomized controlled trial Radwan A Torky, Ashraf A Helmy, Ahmed Ali, Abdallah B Abdallah, Ahmed T Zayan The Egyptian Journal of Surgery 2019 38(2):214-220 Background Laparoscopic surgery in colon cancer is well established, but its use in rectal cancer is still controversial as it needs a long duration of learning curve; moreover, its oncological adequacy is questionable. This study was conducted to compare laparoscopic and open approaches regarding the short term as well as the oncological outcomes. Materials and methods A prospective randomized study was conducted to compare between open and laparoscopic surgeries regarding short-term and oncological outcomes. Two groups (31 patients in LAP group and 32 patients in the OPEN group) were classified in the study. Results A total of 63 patients with rectal cancer included in the study in the period between January 2015 and March 2016 were classified into two groups: LAP group (31 patients) and OPEN group (32 patients). They underwent rectal cancer resection according to the allocated surgery. There was a longer operative time in LAP group with a significant improved short-term outcomes (blood loss, postoperative pain, postoperative hospital stay, and rapid gastrointestinal tract recovery). There was no difference in morbidities and local and distant recurrence between the two groups. The conversion rate was 12.9% in the LAP group, whereas the median number of removed lymph nodes was 12 in the LAP group and 10 in the OPEN group, with no significant difference. Conclusion Laparoscopy can be used safely in rectal cancer resection with an acceptable short-term outcomes, but it is a difficult technique and needs a learning curve. Its oncological outcomes are still a matter of debate.

Double-mesh technique abdominal wall reconstruction for severe rectus diastasis and ventral hernia repairs (two for two) Hassan A Saad, Ahmed M El Teliti, Alaa A Fiad, Ibrahim A.I Heggy The Egyptian Journal of Surgery 2019 38(2):221-230 Introduction Standard rectus plication techniques may not suffice for severe cases of rectus diastasis, especially with ventral hernia. In our study, prosthetic subfascial sublay mesh and onlay mesh may facilitate the repair of severe rectus diastases, especially with concomitant ventral hernias. There is little agreement about the most appropriate technique to repair these defects, in spite of the fact in the prevalence of ventral hernias we are often faced with reinforcement with prosthetic meshes. In the component separation technique, we found high unaccepted recurrence rate. In an attempt to reduce recurrences, we attempt to use sublay mesh and onlay mesh to inforce the defect and prevent or to decrease the recurrence. Our objective was to determine prosthetic mesh practice patterns of onlay and sublay reconstructive methods regarding indications. Patients and methods A total of 32 consecutive patients who underwent abdominal wall reconstruction by means of component separations associated with polypropylene mesh were included. A technique of placing mesh in a sublay manner, deep to the rectus muscles without anterior dissection of rectus abdominis from anterior sheath to avoid damage of its blood supply and damage deep umbilical perforators during dissection ended by onlay mesh on anterior rectus sheath, was applied. The complications were recorded and follow-up data were obtained after double-mesh technique. Aim To use prosthetic polypropylene mesh sublay (above or anterior to the posterior rectus sheath) with another onlay mesh (above the anterior rectus sheath) for rectus diastasis with or without ventral hernia. Results From May 2016 to January 2018, we had 16 patients who underwent cosmetic abdominal repair either for a ventral hernia repair with mesh or a rectus diastasis repair with mesh. Three patients had (isolated) rectus diastasis alone. The mean age of the patients was 55 years, with a range of 35–75 years of age. Overall, 92% of the patients were female. The mean;Deg;BM;Deg;I of the patients was 32 kg/m2 (range: 25–40 kg/m2). There were no surgical-site infections but three surgical-site occurrences − seromas, which were treated with drainage in the office. After an average of 365 days of follow-up, none of the patients had recurrence of a bulge or a hernia. Conclusion This study used a double-mesh reinforcement procedure, with a low rate of recurrence and occurrences. Moreover, the repair of a large, complex hernia by double-mesh repair technique augmented with polypropylene onlay mesh and sublay results in lower recurrence rates compared with historical reports of component separation technique alone.

Failing arteriovenous access: endovascular option Abdulaziz Z AlGaby, Alaa A.H Marzouk, Khaled Shawky, Mohamed H Abdelmawla The Egyptian Journal of Surgery 2019 38(2):231-238 Objective Hemodialysis access is considered the lifeline for patients with end-stage renal disease. So, maintaining it is extremely crucial for these patients. This study is designed to show the rule of percutaneous intervention to maintain their access. Patients and methods It is a prospective study conducted in Beni Suef University hospital from June 2016 to January 2018 on 20 patients with failing arteriovenous (AV) access. They were subjected to endovascular ballooning to relieve stenosis of their access and/or outflow vein. Efficacy, represented by technical success and clinical success, and complications of the procedure were assessed. Results The study revealed that 80% of the patients had technical success. However, 60% of the patients had their symptoms improved and succeeded to maintain their dialysis access. No major complications were attributed to the intervention. There was a strong association between lesions of total occlusion and technical failure. Conclusion Percutaneous treatment of dysfunctional or failing autologous dialysis fistulas can successfully and safely extend functional lifespan. Attention should be paid to lesions of total occlusion as they are difficult to cross and subsequently balloon dilatation.

Aortic remodeling after thoracic endovascular repair of acute uncomplicated type B aortic dissection Hany A Mohamed, Ahmed R Tawfik, Mohammed Ali, Rana K Ali The Egyptian Journal of Surgery 2019 38(2):239-244 Introduction The classical treatment of type B aortic dissection is based on either medical treatment for uncomplicated aortic dissection or open surgery. Now with improvements in endovascular intervention, it seems to be more effective, safe, and with favorable effects on aortic remodeling. Patients and methods This is a retrospective study that aimed to evaluate the effect of thoracic endovascular repair (TEVAR) on remodeling in uncomplicated acute type B aortic dissection. Serial contrast-enhanced computed tomography scans of 32 patients with acute type B aortic dissection were performed and the data were collected between March 2018 and October 2018. Thirteen patients received best medical therapy only and 19 patients received best medical therapy and TEVAR, and the effect of TEVAR on aortic remodeling was compared by a computed tomography scan. Results Data of 32 patients (20 men and 12 women) with a median age of 59 years were collected; the median follow-up period was 6 months. TEVAR resulted in an increase in the true lumen diameter (from 2.0085 to 3.039 cm) and a decrease in the false lumen diameter (from 1.8767 to 0.785 cm). However, in the medical group only, the diameters remained almost unchanged (true lumen diameter ranged from 1.9024 to 2.3898 cm and false lumen diameter ranged from 1.9045 to 1.7245 cm). Conclusion TEVAR for acute type B aortic dissection resulted in a significant increase in the true lumen diameter and decrease in the false lumen diameter.

Comparative study of safety and effectiveness of rivaroxaban and warfarin in patients with acute deep venous thrombosis Yahia M Al Khateep, Nehad A Zaid, Osama R.F Salim The Egyptian Journal of Surgery 2019 38(2):245-249 Objectives To evaluate the safety and effectiveness of the oral anti-factor Xa (rivaroxaban) in comparison with that of traditional oral (warfarin) anticoagulants in patients in acute stage of deep-vein thrombosis. Background Standard treatment for venous thromboembolism (VTE) consists of a heparin combined with vitamin K antagonists. Direct oral anticoagulants have been investigated for acute and extended treatment of symptomatic VTE; their use could avoid parenteral treatment and/or laboratory monitoring of anticoagulant effects. Patients and methods A prospective study was conducted to compare the efficacy and safety of rivaroxaban (15 mg twice daily for 21 days, followed by 20 mg once daily) with standard therapy (enoxaparin 1.0 mg/kg twice daily and warfarin or acenocoumarol). Patients were treated for 3, 6, or 12 months and followed for suspected recurrent VTE and bleeding. Results Our study included 200 patients in the acute stage of deep venous thrombosis. Half of them were treated by oral anti-factor Xa (rivaroxaban), which showed no significant difference in safety and effectiveness with warfarin. Partial and complete recanalization occurred in 64 and 16%, respectively, for rivaroxaban and in 48 and 24%, respectively, for warfarin, whereas pulmonary embolism and bleeding occurred in 8 and 16%, respectively, for rivaroxaban and 16 and 12%, respectively, for warfarin. Rivaroxaban was noninferior to warfarin with respect to primary efficacy and adverse effect outcome. Conclusion Our study results show nonsignificant difference between oral anti-factor Xa and the Low Molecular Weight Heparin (LMWH) and vitamin K antagonist technique in the treatment of acute stage of deep-vein thrombosis, but the oral anti-factor Xa (rivaroxaban) has an upper hand in being orally taken and needs less monitoring of coagulation profile.