The possible utility of global longitudinal strain in the risk-stratifying process of non-ST elevation-acute coronary syndrome

BACKGROUND

There are various ways that coronary artery disease (CAD) might present itself. Individual risk stratification for non ST-elevation-acute coronary syndrome (NSTE-ACS) patients should determine whether invasive coronary angiography and revascularization should be scheduled.

AIM OF WORK

To assess the possible utility of left ventricular global longitudinal strain in the risk-stratifying process of NSTE-ACS.

SUBJECTS AND METHODS

The cardiology department of Zagazig University in Egypt organized and oversaw this cross-sectional study. The practical portion was carried out on 90 patients with NSTE-ACS based on European society of cardiology (ESC) guidelines (and they agreed for invasive strategy) between May 2019 and December 2020 at Salalah Heart Center in Sultanate of Oman. All patients underwent a full clinical examination, 12-lead ECG, and serial high-sensitivity troponin T (hs-TnT) in addition to a thorough history taking process. On patient's admission, the GRACE risk score was assessed. All patients who were suspected of having NSTE-ACS upon admission underwent transthoracic echocardiography, including two-dimensional speckle tracking (2D-ST). Left ventricular global longitudinal strain (LV-GLS %) was measured and analyzed using 2D speckle tracking. SYNTAX Score was determined for all patients.

RESULTS

By analysis of the performance of LV-GLS% in prediction of high risk by GRACE score, we found that with cutoff (≥-13.8), the AUC was (0.944) with sensitivity, specificity, PPV, NPV, and accuracy (0.944, 93.3%, 84%, 53.8%, 98.4%, 85.6%), respectively.

CONCLUSION

Global longitudinal strain can predict accurately high-risk NSTE-ACS patients by GRACE score.

Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial

BACKGROUND

We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy.

METHODS

This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor).

RESULTS

Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition.

CONCLUSION

In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions.

CLINICAL TRIAL REGISTRATION

NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .

Aortic Valve Replacement in Patients with Small Aortic Annulus: New Pericardial Stented Valves vs Aortic Root Enlargement Procedures.. [DOI: 10.22541/au.163943224.41477072/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objectives: Newer generations of stented pericardial valves may offer hemodynamic benefit in patients with small aortic annulus. The aim of this study was to determine the effectiveness of isolated aortic valve replacement with one such valve, the Trifecta valve, when compared to Aortic root enlargement surgery in reducing postoperative gradients and the severity of PPM in patients with small aortic annulus. Patients and methods: A prospective observational study of 100 patients with SAA who underwent AVR from March 2020 to October 2021 in Cairo university hospitals and other centers. The cohort was divided into two groups based on surgical technique: Isolated AVR using Trifecta valve or ARE and mechanical valve placement. Preoperative characteristics, intraoperative times and postoperative outcomes were recorded and compared in all patients, including a pre-discharge echocardiography. Results: Increased operative times, increased ICU stay and need for blood products were observed in the ARE group and operative time was determined as an independent risk factor. Higher rate of complications such as need for permanent pacemaker as well increased postoperative drainage was also recorded in ARE group, with no difference between groups in in-hospital mortality. Higher incidence of PPM was recorded in the Trifecta group (24%) compared to the ARE group (8%). but, the severity of PPM within the Trifecta group was reduced compared to the ARE group, and no degree of PPM was observed in Trifecta valves sized 21. Conclusion The Trifecta valve offers excellent postoperative hemodynamics and significant reduction in severity of PPM in patients with SAA undergoing AVR, with gradients and iEOA almost comparable to larger sized valves implanted after ARE, making the increased surgical burden of ARE unnecessary in most patients.

Boosting of Antioxidants and Alkaloids in Catharanthus roseus Suspension Cultures Using Silver Nanoparticles with Expression of CrMPK3 and STR Genes

Global agricultural systems are under unprecedented pressures due to climate change. Advanced nano-engineering can help increase crop yields while ensuring sustainability. Nanotechnology improves agricultural productivity by boosting input efficiency and reducing waste. Alkaloids as one of the numerous secondary metabolites that serve variety of cellular functions essential for physiological processes. This study tests the competence of silver nanoparticles (AgNPs) in boosting alkaloids accumulation in Catharanthus roseus suspension cultures in relation to the expression of C. roseus Mitogen Activated Protein Kinase 3 (CrMPK3) and Strictosidine Synthase (STR) genes. Five concentrations (5, 10, 15, 20 and 25 mg·L-1) of AgNPs were utilized in addition to deionized water as control. Results reflected binary positive correlations among AgNPs concentration, oxidative stress indicated with increase in hydrogen peroxide and malondialdehyde contents, activities of ascorbate peroxidase and superoxide dismutase, expression of the regulatory gene CrMPK3 and the alkaloid biosynthetic gene STR as well as alkaloids accumulation. These correlations add to the growing evidence that AgNPs can trigger the accumulation of alkaloids in plant cells through a signaling pathway that involves hydrogen peroxide and MAPKs, leading to up-regulation of the biosynthetic genes, including STR gene.

Screening for chronic hepatitis C and chronic hepatitis B infections among pregnant females: a cross-sectional study

Background

In Egypt, an endemic country for both viral hepatitis C and B infections, infection could be more prevalent in pregnant females. This study aimed to assess the prevalence of chronic HCV and HBV in a cohort of pregnant Egyptian females, highlighting the disease burden for better preventive measures and better disease outcome. In this cross-sectional prospective study, 399 pregnant women attending antenatal clinic in a tertiary care center in Egypt were screened for HCV and HBV infection using ELISA testing. Clinical and biochemical characteristics were compared between positive and negative cases.

Results

Mean age was 26.78 years. Prevalence rates of HCV-Ab and HBsAg positivity were 7.02% and 7.52%. Isolated HBcAb positivity was found in only 2 patients (0.5%). All cases were negative for HBsAb. No combined HBV/HCV infection was detected. All positive cases for either HBV or HCV infections did not show any signs of hepatic decompensation. ALT was significantly higher among HBV positive versus negative patients (mean ± SD of 14.2 ± 5.77 IU/L versus 11.95 ± 5.21 IU/L, p = 0.02, reference range: 7-56 IU/L), while no significant difference was found between HCV positive and negative cases as regards liver enzymes.

Conclusion

In Egypt, HBV prevalence in pregnant females seems to be higher than general population. This was not evident for HCV infection; however, it is still higher than pooled prevalence rates worldwide. This higher prevalence for both viral infections warrants strict screening programs to prevent vertical transmission and to provide better maternal and fetal outcome.

The Impact of Rehabilitation-oriented Virtual Reality Device in Patients With Ischemic Stroke in the Early Subacute Recovery Phase: Study Protocol for a Phase III, Single-Blinded, Randomized, Controlled Clinical Trial

BACKGROUND AND RATIONALE

Stroke is considered the most common cause of adult disability. Intensive rehabilitation protocols outperform nonintensive counterparts. The subacute stroke phase represents a potential window to recovery. Virtual reality (VR) has been shown to provide a more stimulating environment, allowing for increased patient compliance. However, the quality of current literature comparing VR with standard therapies is limited. Our aim is to measure the impact of VR versus standard therapy on the recovery of the upper limb motor function in patients with stroke in the early subacute recovery phase.

METHOD

This is a randomized, controlled trial that will assign 262 patients to tailor-made standard rehabilitation (TMSR) or TMSR plus immersive VR device. The trial will be conducted in an urban rehabilitation clinic in the United States with expertise in the management of poststroke patients. Patients will be 18 to 70 years of age and in the early subacute period (30-90 days post ischemic stroke). The primary outcome will be the change of Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score, measured at baseline and 13 weeks after randomization. The secondary outcome will be the change in the UK Functional Independence Measure and Functional Assessment Measure (UK FIM-FAM) score at the same time points.

DISCUSSION

If the use of VR in the rehabilitation of patients with stroke proves to have a significant impact on their motor recovery, it will constitute an extremely important step into decreasing the functional impairment associated with stroke and the related health care expense burden.

Comparative study of tissue adhesive therapy versus band ligation in control of actively bleeding esophageal varices

BACKGROUND AND STUDY AIMS

Bleeding esophageal varices is a common life-threatening emergency that carries a significant morbidity and mortality. Acute variceal bleeding is considered active when spurting and/or oozing varix is seen at the time of endoscopy, or inactive in the presence of large esophageal varices with blood in the stomach with no other bleeding source at the time of endoscopy. Aim: comparing endoscopic variceal ligation (EVL) versus cyanoacrylate injection (CI) in active esophageal variceal bleeding control.

PATIENTS AND METHODS

a retrospective single tertiary center study from April 2014 to February 2018, including 401 patients with active esophageal variceal bleeding.

RESULTS

Endoscopic hemostasis was achieved by both endoscopic variceal ligation in 182 patients (91.9%) and cyanoacrylate injection in 197 patients (97.05%) without significant difference (P value 0. 15). Re-bleeding occurred more frequently in EVL group 20 patients (10.1%) compared to 14 patients (6.9%) in CI (P value 0.01). Early six-week Mortality was higher among EVL group (20.7%) compared to CI (17.2%) without statistical significance (P value 0.3).

CONCLUSION

Both EVL and CI are almost as effective in achieving endoscopic hemostasis. CI is more effective, feasible, and could be used as a salvage therapy and/or spared for risky active bleeding esophageal varices.

Left atrial deformation analysis as a predictor of severity of coronary artery disease

BACKGROUND

Two-dimensional (2D) speckle-tracking strain imaging is a novel method for assessment of regional myocardial deformation that uses tracking of acoustic speckles or kernels rather than Doppler myocardial velocities. It has been suggested that Left atrial (LA) strain as measured by 2D speckle tracking can be used to evaluate dynamic LA function.

OBJECTIVE

To study the relation between left atrial deformation and the severity of coronary artery stenosis in patients with stable coronary artery disease (CAD).

STUDY DESIGN

30 patients with stable coronary artery disease (SCAD) with coronary artery stenosis (>50%) who were admitted for elective coronary angiography at Ain Shams University hospitals and AlAzhar University hospitals were included in the study. Measurements of conventional echocardiographic parameters as well as LA strain and strain rate parameters were obtained, Syntax (SX) score was calculated for all patients.

RESULTS

Patients were categorized into 3 groups: low Syntax score of <23 (Group I), moderate syntax score 23-32 (Group II) and high syntax score of ≥33 (Group III). Peak atrial longitudinal strain (PALS) (Group I: 29.80 ± 4.48, Group II: 22.44 ± 1.42, Group III: 19.53 ± 4.46; p < 0.001) and Peak atrial contraction strain (PACS) (Group I: 13.43 ± 4.05, Group II: 10.84 ± 2.47, Group III: 7.19 ± 0.71; p < 0.022) were significantly lower in high syntax group. Significant negative correlation was found between SX score level and LA strain parameters (PALS and PACS) (r = 0.861; p < 0.001).

CONCLUSION

Left atrial deformation analysis by 2D Speckle tracking Doppler Echocardiography can predict the severity of coronary affection in patients with stable CAD.

Effect of Direct-Acting Agents on Fibrosis Regression in Chronic Hepatitis C Virus Patients' Treatment Compared with Interferon-Containing Regimens

Hepatitis C virus (HCV) treatment is aiming to cure and prevent the development, progression of fibrosis, and related complications. Interferon-based therapy was claimed to reduce or even reverse fibrosis. Although direct-acting agents have a better cure rate, we still lack the knowledge of their effect on fibrosis regression. We aim to assess fibrosis regression in direct-acting agents compared with interferon-based treatment regimens in the treatment of chronic HCV patients. The 204 chronic HCV patients were divided into 3 groups; group 1(N = 68) received Peg-IFN and ribavirin, group 2 (N = 69) received sofosbuvir and ribavirin, and group 3 (N = 67) received Peg-IFN, ribavirin, and sofosbuvir. Fibrosis assessment was performed by transient elastography (TE), APRI and FIB 4, in the pretreatment and at least 3 months after end of treatment. Of these, 66.2% of the patients did not show significant fibrosis changes, 6.4% fibrosis progressed, and 27.5% of fibrosis regressed (P < 0.0001) by TE. Similar results were detected in the different treatment regimens with no statistically significant difference between the regimens. Fibrosis regression was detected in 43.3% of cirrhotic patients who achieved sustained virological response (SVR) and only in 27.4% with significant fibrosis. Significant improvement of posttreatment aspartate transaminase, alanine transaminase, and alpha fetoprotein as well as APRI and FIB 4 scores were detected. Fibrosis regression (TE, APRI and FIB 4) was detected with direct-acting agents and interferon-based therapy. Treated patients with significant fibrosis will benefit of fibrosis regression irrespective to their treatment response, whereas fibrosis regression was associated with SVR in cirrhotic patients.

Surface and intracranial EEG spike detection based on discrete wavelet decomposition and random forest classification

Epilepsy is a neurological disorder for which the electroencephalogram (EEG) is the most important diagnostic tool. In particular, this diagnosis heavily depends on the detection of interictal (between seizures) paroxysmal epileptic discharges (IPED) in the EEG. This is a time-consuming task requiring significant training and experience. Automatic detection of these EEG patterns would greatly assist visual inspections of human readers. We present a new method, which allows automatic detection of IPED based on discrete wavelet decomposition and a random forest classifier. The algorithm was trained and cross validated using 17 subjects with scalp EEG and 10 subjects with intracranial EEG. The performance of this method reached 62% recall and 26% precision for surface EEG subjects and 63% recall and 53% precision for intracranial EEG subjects. Thus, the method hereby proposed has great potential for diagnosis support in clinical environments.

The accuracy and cost-effectiveness of hepatitis C core antigen assay in the monitoring of anti-viral therapy in patients with chronic hepatitis C genotype 4

BACKGROUND

Quantitative hepatitis C (HCV) polymerase chain reaction (qtHCV-PCR), the gold standard for monitoring HCV therapy, is an expensive, time-consuming procedure that requires equipped laboratories and trained personnel.

AIMS

To assess the accuracy and cost-effectiveness of the automated Abbott ARCHITECT HCV Ag assay (Wiesbaden, Germany) in monitoring response to pagylated interferon (PEG-IFN) and ribavirin therapy for chronic HCV genotype 4 (G4).

METHODS

This longitudinal, non-inferiority study compared the efficacy and cost benefit of an All-HCV core antigen assay protocol and a hybrid qtHCV RNA PCR and HCV core Ag assay protocol to the standard All-qtHCV-PCR protocol in chronic HCV G4 patients treated with pegylated interferon (PEG IFN) and ribavirin.

RESULTS

Four hundred and ten patients with chronic hepatitis C genotype 4 met inclusion criteria and were enrolled in the study. The sustained virological response rate (SVR) was 66.34%. The All-HCV core antigen and hybrid monitoring assays resulted in the significant cost savings without compromising performance. A good correlation existed between HCV viral load and HCV core antigen levels (r = 0.944; P < 0.0001). Baseline HCV RNA values <600 IU/mL, baseline HCV core Ag levels <2000 fmol/L, rapid virological response, rapid decline in HCV core antigen were strong predictors of SVR.

CONCLUSION

Hepatitis C core Ag assay is a point-of-care, reproducible, reliable, cost-effective monitoring tool with rapid turnaround time that, which can effectively replace or adjunct to qRT-PCR in monitoring interferon based or interferon-free anti-viral therapy in chronic hepatitis genotype 4 patients in resource-limited countries with a high burden of hepatitis C.

Relation of ALT and AST levels to the histopathological changes in liver biopsies of patients with chronic hepatitis C genotype 4

BACKGROUND AND STUDY AIMS

Worldwide, Egypt has a high prevalence of adult hepatitis C virus (HCV) infection. Serum alanine aminotransferase (ALT) activity is most commonly measured to assess hepatic disease. The revision of the definition of the normal limits for the ALT level is advisable. The aim of this work was to compare the histopathological changes in the liver tissue biopsies of HCV-infected patients, clinically presenting with ALT levels below normal, based on the conventional, previously used upper limit of normal (ULN) of ALT (40U/L for men and 30U/L for women) with the proposed new ULN (30U/L for men, and 19U/L for women).

PATIENTS AND METHODS

This is a retrospective cross-sectional study. A total of 668 cases of chronic hepatitis C genotype 4 were included. Patients were classified according to grades of histological activity and fibrosis stages (by the Metavir scoring system). They were also classified into normal and high groups according to the old and new cutoffs of both aspartate transaminase (AST) and ALT levels.

RESULTS

The results of our study showed that the serum AST level in our study showed a better correlation with the histopathological changes in liver biopsy rather than ALT, especially when using the old cutoff of the ULN for AST. The serum ALT level in our study (both the old and the new cutoffs) did not show a significant correlation with the histopathological status in the liver biopsies of our patients.

CONCLUSION

This study concluded that the old cutoff of the ULN AST is a better predictor of fibrosis.

Role of transforming growth factor-β1 in serum and - 509 C>T promoter gene polymorphism in development of liver cirrhosis in Egyptian patients

Objectives

Liver cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. HCV is one of the major causes of liver fibrosis and ultimate progression to cirrhosis. Transforming growth factor-beta1 (TGF-β1), one of the three isoforms of TGF-β, is a pleiotrophic cytokine that regulates the proliferation and differentiation of cells, embryonic development, wound healing and angiogenesis. This study aimed to evaluate the role of serum TGF-β1 and − 509 C>T promoter gene polymorphism in the development of liver cirrhosis.

Design and methods

Besides routine liver profiles, serum TGF-β1 was measured in 40 liver cirrhosis patients and 40 controls using ELISA technique. TGF-β1 − 509 C>T promoter gene polymorphism was detected using PCR-RFLP technique.

Results

TGF-β1 − 509 CT and TT genotype frequencies were significantly higher in the cirrhotic group (52.5%, 25%; respectively) than control group (10%, 7.5%; respectively); OR = 16.238 (95% CI 5.391–48.914, p < 0.05). The − 509 T allele carriers are more prone to develop liver cirrhosis than − 509 C allele carriers; OR = 7.359 (95% CI 3.325–16.288, p < 0.05). Serum TGF-β1 was significantly higher in cirrhotic group (11.79 ± 1.45 ng/ml) than control group (8.67 ± 1.23 ng/ml); p < 0.05. Also serum TGF-β1 was significantly higher in TT genotype than CT and CC genotypes (p < 0.05). A significant positive correlation was observed between serum TGF-β1 and alkaline phosphatase (r = 0.559, p < 0.05); AST (r = 0.573, p < 0.05). A significant negative correlation was observed between serum TGF-β1 and albumin (r = − 0.331, p < 0.05).

Conclusion

There is an association between serum TGF-β1, − 509 CT and TT genotypes of TGF-β1 gene and the higher risk for liver cirrhosis development of liver cirrhosis.

Fibroscan of chronic HCV patients coinfected with schistosomiasis

BACKGROUND AND STUDY AIMS

Both hepatitis C virus (HCV) and schistosomiasis are highly endemic in Egypt and coinfection is frequently encountered. Such coinfection is responsible for leading to a more severe liver disease. Hence, the aim of the study was to assess the fibroscan in chronic HCV patients coinfected with Schistosoma.

PATIENTS AND METHODS

This study included 231 chronic HCV patients. Routine pre-treatment work-up was done including anti-schistosomal antibodies. Liver stiffness measurements using fibroscan and reference needle-liver biopsy were done. Patients were categorised into two groups: HCV patients with positive schistosomal serology and HCV patients with negative schistosomal serology.

RESULTS

Anti-schistosomal antibody was positive in 29% of the studied population. Positive schistosomal serology status was significantly associated with the disagreement between the results of liver biopsy (Metavir) and the fibroscan results (p value=0.02), which was more obvious in F2 and F3 fibrosis stages. The sensitivity of fibroscan for the detection of the F2 stage decreased from 64% among negative schistosomal serology patients to 30.8% among positive schistosomal serology patients, and for the F3 stage it decreased from 43.8% to 21.4%, respectively. Multivariate logistic regression showed that fibrosis stages (F0-F1 and F4) were the most independent factors that were associated with the agreement between fibroscan and liver biopsy (odds ratio (OR) 3.4, 7.12 and p value <0.001, <0.001, respectively).

CONCLUSION

Although the sensitivity of fibroscan for the detection of fibrosis stages (F2 and F3) was impaired in patients with positive schistosomal serology, fibrosis stages (F0-F1 and F4) were the most independent factors associated with the agreement between fibroscan and liver biopsy.

Detection of aberrant p16INK4A methylation in sera of patients with HCV-related liver diseases: An Egyptian study

BACKGROUND

The present study was performed to estimate the frequency of methylated p16INK4A in the sera of patients with hepatitis C virus (HCV)-related chronic active hepatitis (CAH), liver cirrhosis (LC), and hepatocellular carcinoma (HCC) and to evaluate the role of p16INK4A as a tumor marker of HCC.

MATERIAL/METHODS

The sera of 17 CAH, 20 LC, and 25 HCC patients were examined in this study. The methylation status of p16INK4A was evaluated by methylation-specific PCR of the serum samples.

RESULTS

Methylated p16INK4A was detected in 47.1% (8/17) of the CAH patients, 5% (4/20) of the LC patients, and in 92% (23/25) of the HCC patients. HBV markers were detected in (4/25) of HCC patients; all had methylated p16INK4A. No association was demonstrated between p16INK4A methylation and serum AFP level in the HCC group.

CONCLUSIONS

The results of this study indicate that aberrant DNA methylation contributes to hepatocarcinogenesis and it may be an early event during hepatocarcinogenesis. As the status of p16INK4A methylation was not associated with serum AFP level, it may have a complementary role with AFP as a tumor marker of HCC.

Surgical management of peri-ampullary tumors: a retrospective study

BACKGROUND/AIMS

Surgical resection still remains the best treatment for patients with periampullary tumors. This study aims to present the results of surgical treatment of this disease at our center.

METHODOLOGY

Between January 1995 and December 2004, 216 periampullary tumors were treated by surgical resection. The mean age was 58 years with male to female ratio 2:1. The most common symptom was jaundice (97.7%). Abdominal pain occurred in 74% of patients. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients.

RESULTS

Operative mortality occurred in 7 patients (3.2%). The median survival was 22.6 months for patients with ampullary tumors and 16.6 months for patients with pancreatic head tumors. Early operative complications occurred in 33% of patients; the most common one was wound infection (11.6%), pancreatic leak (10.6%), abdominal collection (10.6%) and delayed gastric emptying (8.8%). Factors associated with increased risk of developing complications were the type of pancreatico-enteric anastomosis (pancreatic leak was more frequent with pancraticojejunostomy), soft pancreatic texture and intraoperative blood transfusion of more than 4 units. Factors associated with better survival included tumor diameter (less than 3cm), origin (ampullary), differentiation (well differentiated) and margin status (negative resection margins).

CONCLUSIONS

Postoperative complications of pancreaticoduodenectomy, especially with the adoption of pancreaticogastrostomy, occur with reasonable incidence. Survival largely depends on the origin of the tumor.

216 cases of pancreaticoduodenectomy: risk factors for postoperative complications

BACKGROUND/AIMS

Surgical resection remains the best treatment for patients with periampullary tumors. Many series have been reported with low or zero mortality, however, high incidence of complications is the rule. This study aims to present the results of pancreaticoduodenectomy and factors predisposing to postoperative complications, especially pancreatic leak, at our center.

METHODOLOGY

Between January 2000 and December 2006, 216 periampullary tumors were treated by Whipple pancreaticoduodenectomy. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients. Hospital mortality and surgical complications were recorded with special emphasis on pancreatic leak. All specimens were histologically examined for the presence and origin of malignant tissue.

RESULTS

The mean age was 58 years and male to female ratio was 2:1. The commonest symptom was jaundice (97.7%) followed by abdominal pain (74%). Operative mortality in 7 patients (3.2%). 71 (33%) patients developed 1 or more complications, pancreatic leak occurred in 23 (10.6%) patients, abdominal collection in 23 patients (10.6%) and delayed gastric emptying in 19 (8.8%) patients. Factors that influenced the development of postoperative complications included type of pancreaticoenteric anastomosis, pancreatic texture and intraoperative blood transfusion of 4 or more blood units. Pancreatic leak was commoner with PJ (p=0.001), soft pancreatic texture (p=0.008), intraoperative blood transfusion of 4 or more units (p<0.0001). Periampullary adenocarcinoma was found in 204 (94.4%) patients, chronic pancreatitis in 9 (4.2%) patients, 2 patients with solid and papillary neoplasm, and 1 patient with NHL (Non-Hodgkin's Lymphoma).

CONCLUSIONS

Surgery is the only hope for patients with periampullary tumors. Postoperative complications after pancreaticoduodenectomy depend largely on surgical technique and can be reduced reasonably with the adoption of pancreaticogastrostomy, which is safer and easier to learn than pancreaticojejunostomy.

Short gastric vessels division in Laparoscopic Nissen Fundoplication

BACKGROUND/AIMS

To divide or not the short gastric vessels during Laparoscopic Fundoplication (LF) is still controversial. This retrospective study is based on short gastric vessels division (SGVsD), if necessary, during LF to construct a satisfactory loose wrap and to evaluate its effect upon the symptomatic and physiologic outcome in patients with proven GERD.

METHODOLOGY

150 patients (90 males, 60 females) with a mean age of 37 +/- 9 with typical symptoms of GERD, adequate motility study and positive 24-hour pH studies underwent LF; 100 (66.7%) were feasible after careful and complete fundal dissection without SGVsD while, 50 (33.3%) were not possible except with SGVsD. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; repeated upper endoscopy and barium study. Postoperative 24-hour esophageal pH and LES manometry were performed in 110 patients.

RESULTS

The mean operative time was prolonged with short gastric division (130 +/- 60 vs. 90 +/- 40 minutes). At a mean period of follow-up of 35 +/- 12 months, relief of the primary symptom responsible for surgery was achieved in 92.2% of patients with division and 87.5% of patients without. Recurrent attacks of abdominal distension were documented in 2 patients (5.6%) with division and 12 patients (16%) without division. Occasional dysphagia not present before surgery occurred in 27 patients at 3 months; 11 (31.4%) with division and 16 (21.3%) without, and decreased to 11 patients by 12 months after surgery; 2 (5.7%) with division and 9 (12%) without; only one case of those without division required 5 sets of endoscopic dilatation. Endoscopic esophagitis healed in all patients with division and 71 of 75 patients (94.7%) without. LES pressures had returned to normal in all patients except one case without division (1.3%) with a higher mean pressure among those without division (22.3 mmHg vs. 18.5 mmHg) and a better relaxation with division (89.9% vs. 80.5%). 24-hour esophageal acid exposure had returned to normal in 33 of 35 patients (94.3%) with division and 66 of 75 patients (88%) without.

CONCLUSIONS

Construction of a satisfactory loose Nissen Fundoplication was feasible in two thirds of patients without SGVsD. Despite prolongation of the operative time, SGVsD provides a better symptomatic and physiologic outcome.

Laparoscopic cholecystectomy: a report on 2000 cases

BACKGROUND/AIMS

This is a retrospective study to evaluate the results of laparoscopic cholecystectomy after 2000 cases at a single center.

METHODOLOGY

Between June 1992 and February 2000, 2000 patients (1458 females and 542 males, mean age 39.8 years) with symptomatic gallstones underwent laparoscopic cholecystectomy. All cases were diagnosed by abdominal ultrasonography. Preoperative endoscopic retrograde cholangiopancreatography was done for 31 patients. Four trocars were used for all except 20 cases.

RESULTS

The mean operative time was 45 +/- 15 minutes. Conversion to open cholecystectomy occurred in 147 patients (7.35%). Adhesions were the commonest cause of conversion (2.9%). There was no technique-related mortality. Bile duct injury occurred in 7 cases (0.35%), reconstruction by Rouxen-Y hepaticojejunostomy was necessary in 5 cases and the injury was successfully managed by endoscopic stent in 2 cases. Bile leakage occurred in 11 cases (0.55%), peritonitis in 5 cases (0.25%), internal hemorrhage in 9 cases (0.45%), cystic artery injury in 17 cases (0.85%), pneumothorax in one case (0.05%) and subcutaneous emphysema in 3 cases (0.15%).

CONCLUSIONS

Laparoscopic cholecystectomy is a good alternative to open cholecystectomy with an acceptable morbidity. Conversion to open cholecystectomy at the proper time will prevent major complications.

Outcome after resection of central cholangiocarcinoma: preliminary experience with 46 patients in a single center

BACKGROUND/AIMS

Despite the enormous progress in surgery the management of cholangiocarcinoma remains a problem. In this study we present our preliminary experience in the surgical treatment of central cholangiocarcinoma.

METHODOLOGY

Between May 1997 and December 2001, 175 patients with central cholangiocarcinoma were admitted to our center. Of the 175 patients, 54 cases subjected to surgery, the remaining 131 patients did not undergo surgery because of advanced disease, advanced liver cirrhosis and poor general condition. Forty-six patients underwent surgical excision, their mean age was 53 +/- 3 years, and male to female ratio was 74-26%. All patients presented with jaundice associated with pain (30%) or biliary stones (32%). Surgical resection of the bile duct with or without part of segment IV were done in fourteen patients and bile duct resection together with major hepatectomy had been done in the remaining 28 patients.

RESULTS

Hospital mortality occurred in 10.8%; the main cause of mortality was hepatic cell failure. The most common complications were hepatic cell failure that occurred in 7 cases (15%), biliary leakage in 8 cases (17%), gastrointestinal bleeding in 3 cases (6.5%) and wound infection in 3 cases (6.5%). Late complication in the form of recurrence occurred in 12 cases (29.5%). cholangitis in 8 cases (19.5%), hepatic cell failure in 5 (12%) and gastrointestinal bleeding in 2 (4.8%). At the end of the study, 19 patients (46%) were alive with mean follow-up of 16.6 +/- 9 months. The survival rate at 6, 12, 18, 24 months was 92, 82, 52, 25, 18%, respectively. Recurrence and cholangitis were found significantly higher in the group without hepatectomy than the group after hepatectomy (p < 0.0001, p < 0.0016, respectively).

CONCLUSIONS

From our results we can conclude that major hepatectomy with excision of the extrahepatic bile duct system and caudate lobe resection may be recommended for the surgical treatment of central cholangiocarcinoma in selected cases.

Modified pancreaticoduodenectomy: experience with 81 cases, Wahab modification

BACKGROUND/AIMS

Now pancreaticoduodenectomy is considered a safe and acceptable line of treatment for periampullary tumors. In spite of improvements in the surgical technique it still has a high morbidity rate. In this study we introduce new technical modifications for the original procedure aiming to decrease the incidence of morbidity.

METHODOLOGY

Between 1994-2000, 210 pancreaticoduodenectomies were done in the Gastroenterology Center, Mansoura University, Egypt for periampullary tumor. Eighty-one of these patients were subjected to modified pancreaticoduodenectomy. They were 57 men and 34 women with a mean age of 54 (+/- 8) years. Pancreatic carcinoma represented 54%, ampullary tumor 30%, bile duct carcinoma 5% and duodenal carcinoma 1.2%. The mean operative time was 3.7 +/- 0.5 hours and mean estimated blood loss during surgery was 733 +/- 48 mL.

RESULTS

Hospital mortality occurred in 3.7% with an overall morbidity rate of 32%. The most common complications were delayed gastric emptying 8.9%, pancreatic fistulae 3.8%, wound infection 6.4%, biliary leakage 3.8% and bleeding 5%. The mean postoperative hospital stay was 9.4 +/- 1 days, with mean time for starting oral feeding 6 +/- 0.9 days. Late mortality occurred in 46% for the entire group with mean follow-up 22 +/- 19 months with actuarial survival for 1, 2, 3, 4, and 5 years being 80, 45, 25, 15, and 10%, respectively.

CONCLUSIONS

It was found that this new modification made the operation easier with shorter operative time, less blood transfusion, low incidence of morbidity and short hospital stay. Moreover, it takes the advantages of lowering the incidence of biliary gastritis, cholangitis and peptic ulcer.

Is resection for large hepatocellular carcinoma in cirrhotic patients beneficial? Study of 38 cases

BACKGROUND/AIMS

Hepatocellular carcinoma in cirrhotic patients generally carries a poor prognosis either due to recurrence or to postoperative morbidity or both. Several factors affect the prognosis of hepatocellular carcinoma resection as presence of cirrhosis of the liver, tumor diameter and tumor capsulation.

METHODOLOGY

Thirty-eight patients with large hepatocellular carcinoma greater than 5 cm with a background of cirrhotic liver were divided into two groups according to tumor diameter. Group A (n = 20) with tumors less than 10 cm in diameter, and group B (n = 18) with tumors larger than 10 cm. All patients underwent preoperative investigations including clinical laboratory tests, sonography, computed tomography, selective angiography and upper gastrointestinal endoscopy. All patients were subjected to different types of hepatic resection.

RESULTS

A significant difference in tumor size, capsulation, and operation time were recorded between the two groups, of patients. No significant difference was detected between both groups regarding sex, age, viral markers, pathologic features, and Child classification. Hospital mortality occurred in 5% versus 11.1% of both groups, respectively. Postoperative jaundice and ascitis occurred in 30%, 35% versus 44.4%, 72.0%, respectively (P < 0.005, P < 0.04). Late mortality occurred in 65% of patients in group A and in 77% of group B. Recurrence was detected in 42% of group A and 62% in group B. Recurrence after resection in capsulated tumors was significantly lower than in noncapsulated tumors in group A (P < 0.01), but not significant in group B. Also, survival rate in patients with capsulated tumors was significantly better in both groups (P < 0.01) than that with noncapsulated tumors.

CONCLUSIONS

Resection of hepatocellular carcinoma with diameter larger than 10 cm recorded bad prognosis regarding recurrence and mortality rates than tumors less than 10 cm. However, capsulated tumors gave better postoperative prognosis than noncapsulated ones.

Hepatocellular carcinoma in Mansoura-Egypt: experience of 385 patients at a single center

BACKGROUND/AIMS

Hepatocellular carcinoma is one of the commonest malignancies in the world. The two main etiological factors for hepatocellular carcinoma are cirrhosis and viral hepatitis. Although the first choice of treatment for hepatocellular carcinoma is surgical resection, most of them are unresectable at the time of diagnosis.

METHODOLOGY

From January 1994 to June 1999, 385 patients with hepatocellular carcinoma were presented to the Gastroenterology surgical center, Mansoura University, Egypt and subjected to similar diagnostic process. Forty-five (11.6%) of these patients (34 males and 13 females) with a mean age of 50.9 years (+/- 7.53 years) were subjected to different types of hepatic resection.

RESULTS

The underlying liver pathology was cirrhosis in 85%. Positive virology was found in 82.5% (HCV 61%, HBV 14.5% and combined 7%). The main presentation were asymptomatic in 144 (37.4%) patients, abdominal pain in 92 (23.9%) patients, ascites in 95 (24.6%) patients, jaundice in 53 (14%) patients and upper gastrointestinal hemorrhage in 26 (6.75%) patients. Only 45 (11.6%) were resectable, they were subjected to hepatic resection with operative mortality in 2 cases (4.4%) and with overall mortality in 29 (64.4%) cases after 48 months (32.8 +/- 19 months) of follow-up. The main causes of late mortality were recurrence in 14 (31.1%) cases, hepatic cell failure in 7 (15.5%) cases and other causes in 6 (13.3%).

CONCLUSIONS

Hepatocellular carcinoma is now a common malignancy in Egypt, which usually develops on top of cirrhosis of viral origin in 82%. Hepatic resection is the only method of treatment with a low resectability rate.

Endodontic interappointment flare-ups: a prospective study of incidence and related factors

Severe pain and/or swelling following a root canal treatment appointment are serious sequelae. Information varies or is incomplete as to the incidence of these conditions and related factors. In this study, data were collected at root canal treatment appointments on demographics, pulp/periapical diagnoses, presenting symptoms, treatment procedures, and number of appointments. Patients that then experienced a flare-up (a severe problem requiring an unscheduled visit and treatment) had the correlating factors examined. Statistical determinations were by chi-square analysis with significance at 0.05 or less. Nine hundred forty-six visits resulted in an incidence of 3.17% flare-ups. Flare-ups were positively correlated with more severe presenting symptoms, pulp necrosis with painful apical pathosis, and patients on analgesics. Fewer flare-ups occurred in undergraduate patients and following obturation procedures. There was no correlation between patient demographics or systemic conditions, number of appointments, treatment procedures, or taking antibiotics.

Central nervous system metastasis from breast carcinoma. Autopsy study

Central nervous system (CNS) metastasis was noted in 309 patients of 1044 autopsy cases of breast carcinoma. The brain was involved in 193 cases, and cranial dura in 167 cases. In 82 cases, the cranial dura was the sole site of CNS involvement. Metastasis to the leptomeninges was found in 59 cases, and to the spinal cord and dura in 32 cases. Metastases to the infratentorial portion of the brain was almost as frequent as to the cerebrum. Forty-two percent of the brain metastasis were single lesions, which is similar to the frequency of solitary metastasis to the brain from malignant tumors as a whole. CNS metastasis occurred more frequently in younger patients than older patients, and the clinical course of these patients was shorter than for those patients without CNS metastasis. CNS metastasis developed in the late stage of the disease, and often was not recognized clinically. Only 31% of the cases were clinically diagnosed or suspected before death. A median survival of these patients after clinical diagnosis of CNS metastasis was 33 days. However, a significant improvement was noted in the clinical diagnosis and median survival in the latter half of the study period. Eleven patients lived for more than 1 year after diagnosis of CNS metastasis. Only 14% of the 309 patients died from CNS failure.