Surgery

ORIGINAL ARTICLES
	A prospective, randomized study of drug-coated balloon versus plain old balloon angioplasty in management of femoropopliteal artery disease in diabetic patients: 12-month results	p. 1
	Ahmed K Gabr, Ahmed K Allam DOI:10.4103/ejs.ejs_60_18   Background/Purposes Despite enhanced immediate technical success, neointimal hyperplasia and restenosis remain the Achilles' heel of endovascular interventions. Drug-coated balloons (DCBs) have shown promise in improving the outcomes of patients with peripheral arterial disease. Several trials have shown that DCB angioplasty has superior antirestenotic efficacy in the femoropopliteal artery (FPA) disease. This controlled, prospective, multicenter study was designed to establish the efficacy of DCB to improve angiographic outcomes and inhibit restenosis of the FPAs in an exclusive diabetic population in a 12-month follow-up period. Aim This controlled, prospective, multicenter study was designed to establish the efficacy of DCB to improve angiographic outcomes and inhibit restenosis of the FPAs in an exclusive diabetic population in a 12-month follow-up period. Settings and design A randomized, controlled, prospective, and multicenter study was conducted. Patients and methods Between January 2016 and December 2017, 84 consecutive adult patients with type 1 and 2 diabetes with oral euglycemics or insulin injection had been enrolled. Overall, 42 patients were treated with DCB angioplasty and 42 were treated with plain old balloon angioplasty (POBA) in a 1 : 1 randomization pattern. The primary end point of the study was the primary patency, mean diameter restenosis, and binary restenosis of the treated sites at 12 months without reintervention in the interim. Results The 12-month mean diameter restenosis was significantly lower in the DCB arm than in the POBA group (27.9±35.1 vs. 44.8±33.9%, P=0.034). Furthermore, analysis showed that the binary (≥50% diameter stenosis) restenosis rates were significantly lower in DCB patients as compared with the POBA patients (28 vs. 47%, P=0.029). The primary patency was significantly better in DCB group (71 vs. 49%, P=0.028). On the contrary, we noted that the rate of clinically driven target lesion revascularization was slightly higher in the POBA patients, though not statistically significant as compared with the paclitaxel-coated balloon group (28 vs. 20%, P=0.13). There were no procedure-related or device-related deaths in either study arm. The 12-month adverse effects, in terms of all-cause death (N3=7.1% POBA vs. N2=4.8% DCB), minor amputation (N5=12% POBA vs. N4=9.5% DCB), major amputation (0% POBA vs. N1=2.4% DCB), and myocardial infarction (N1=2.4% POBA vs. 0% DCB) were equal in both groups (P=713). Causes of mortality included myocardial infarction, cerebral infarction, and sudden death. Conclusions The treatment of diabetic peripheral arterial disease of FPA disease with IN.PACT paclitaxel-coated balloon angioplasty is associated with superior antirestenotic efficacy that provides a better primary patency rate compared with POBA at 12 months. However, DCB showed no clinical benefit over POBA at this 12-month follow-up period. The number of major adverse clinical events was comparable between DCB and POBA groups of patients.
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	Management of multiple cryptoglandular anal fistulas: evaluation of combined fistulotomy and seton application techniques	p. 12
	Walid M Abd El-Maksoud, Khaled S Abbas DOI:10.4103/ejs.ejs_72_18   Aim The aim of this study was to evaluate combined fistulotomy and/or seton application for the management of multiple cryptoglandular anal fistulas in terms of recurrence and postoperative fecal incontinence. Patients and methods This study was carried out in Alexandria Main University Hospital, Alexandria, Egypt, by revising the medical files of all patients with multiple anal fistulas, who underwent fistulotomy, seton application or combined techniques, during the period spanning from December 2013 to June 2016. Results Twelve (10 male patients and two female patients) patients were reviewed, with a mean age of 41.75±7.75 years. Number of multiple fistulas had a mean of 2.58±0.90. For 11 patients, fistulotomy was performed for one or two fistulas (inter-sphincteric or low trans-sphincteric). The rest of the fistulas were treated by two-stage seton fistulotomy or draining seton application. One patient had two high trans-sphincteric anteriorly located fistulas, and both were treated by application of a draining seton. Among 31 fistulas in our patients, recurrence was encountered in two anterior high trans-sphincteric fistulas (6.4%) in two (16.7%) patients. Twelve months after the last intervention, our patients expressed acceptable continence status. Conclusion The condition of multiple cryptoglandular anal fistulas is an uncommon category of anal fistula. MRI is a perfect tool to diagnose the condition preoperatively. Combined fistulotomy and seton application seem a safe strategy for management of multiple anal fistulas with low postoperative recurrence and good postoperative continence. Further studies are required to explore more details about this neglected category of anal fistula.
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	The role of angioplasty in haemodialysis patients with symptomatic venous hypertension owing to central venous stenosis	p. 19
	Mahmoud S Eldesouky, Hesham A Greda, Mohammed A Elbalshy DOI:10.4103/ejs.ejs_86_18   Background Central venous stenosis (CVS) is a serious problem in hemodialysis (HD) patients, often presenting with symptoms of venous hypertension. Endovascular treatment is aimed to provide symptomatic relief and to maintain HD access patency. Aim To evaluate our experience in the endovascular treatment of CVS in HD patients and to determine the relationship between the temporary catheter insertion, the type of arteriovenous fistula, and development of CVS. Patients and methods A prospective study was carried out on 30 patients with End Stage Renal Disease (ESRD) undergoing HD presented with symptomatic venous hypertension in the same side of vascular access, between October 2015 and October 2017. All the patients underwent endovascular treatment and were analyzed. ResultsA total of 30 (20 male and 10 female) patients underwent endovascular interventions for CVS during a time period of 2 years, where 20 stenotic segments were in subclavian vein, six in innominate vein, and four in iliac veins. The technical success rate for endovascular treatment was 80%. Eighteen (75%) patients were treated by ballooning of the stenosed segment alone, whereas six (25%) patients needed primary stenting owing to tight recoiling of the stenotic lesion. Four patients needed reintervention during follow-up (three cases managed by balloon dilatation alone and one needed venous stent after dilatation). Conclusion Endovascular treatment is safe and effective in managing CVS. The incidence of CVS is higher with central venous catheter insertion and proximal arteriovenous fistula.
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	Extending indications of laparoscopic mesh repair of unilateral inguinal hernia in males, is it possible?	p. 26
	Ahmed M Hussein DOI:10.4103/ejs.ejs_88_18   Background Inguinal hernia repair is one of the most commonly performed operations in general surgery departments. Open Lichtenstein procedure is the gold standard in managing such cases. Mini-invasive approaches have gained popularity in the recent few decades by achieving better cosmetic results, shorter hospital stay, less postoperative pain, and earlier return to normal activities. Transabdominal preperitoneal (TAPP) mesh repair is one of the most accepted procedures among surgeons and patients.Aim To compare open Lichtenstein with TAPP mesh repair techniques in unilateral inguinal hernia in male patients regarding perioperative outcome and complications. Patients and methods This is a randomized comparative prospective study conducted from October 2016 to February 2017 on 71 cases presented with unilateral inguinal hernia and divided randomly into two groups: laparoscopic group (28 cases) and open group (43 cases). Both groups were studied and followed up for 1 year postoperatively, detecting intraoperative and early and late postoperative outcomes. Results The mean age was 36±15 years, and comorbidities were present in 32.4% of cases. Left, oblique, and funicular type were the most frequent cases. Operation time was 111±22 min in TAPP group and 75±16 min in open group. Occult hernia was detected in five (17.9%) cases, indirect hernia in three cases, and direct hernia in the other two cases of TAPP group. Intraoperative and postoperative complications were encountered in 10.7 and 28.6% of TAPP group, respectively, and in 9.4 and 20.9% of open group, respectively. Postoperative hospital stay was 2±1 day in both groups. Conclusion TAPP procedure can be performed safely in unilateral inguinal hernia in males with no serious complications. Moreover, it increases the ability to detect and repair the occult hernia in the same session. Longer operation time is the only drawback.
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	Comparative study between brachiocephalic fistula and proximal radiocephalic fistula for hemodialysis in patients with end-stage renal disease	p. 33
	Mahmoud S Eldesouky, Asem Fayed DOI:10.4103/ejs.ejs_92_18   Objectives To evaluate the proximal radiocephalic arteriovenous fistula (AVF) versus brachiocephalic fistula for hemodialysis in terms of patency and complications. Background The distal radiocephalic fistula at wrist is the gold standard AVF for hemodialysis as it reduces the incidence of steal syndrome but with high failure rate. If distal vessels are not suitable or exhausted, elbow fistula is a good vascular access but with increased incidence of steal syndrome, so doing proximal radiocephalic AVF is a good alternative option. Patients and methods A prospective randomized study including 60 patients in need for hemodialysis access was done between January 2016 and January 2017 and was followed up to July 2017 at Menoufia University Hospital. The patients were randomly categorized into two groups including 30 patients in each group. Primary success rate, primary patency, secondary patency rates, and complications of each group were collected and analyzed. Results In the proximal radiocephalic group, primary fistula failure was 0%, while six (20%) fistulas failed later, four of them due to thrombosis, one due to anastomotic aneurysm and the other due to severe venous hypertension. No patients developed steal syndrome, whereas in the brachiocephalic group, primary fistula failure was also 0% and six (20%) fistulas failed later on, three of them due to thrombosis, one due to anastomotic aneurysm, one due to venous hypertension, and the last one due to steal syndrome. Primary patency rates for both proximal radiocephalic and brachiocephalic groups at 6 months were 63.3 and 65.1%, respectively, whereas the secondary patency rates at 6 months were 73.3 and 75.4%, respectively. Conclusion For patients with exhausted or unsuitable wrist vessels, we believe that a proximal radiocephalic, should precede creation of brachiocephalic fistula as it had nearly the same patency and complications rates but it avoided the risk of dialysis associated steal syndrome.
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	Effect of lymph node density in the prognosis of patients after pancreatic cancer resection	p. 39
	Mohammed Faisal, Hamada Fathy, Amr Hassan, Mohammed K.E Elhadry DOI:10.4103/ejs.ejs_98_18   Background Pancreatic cancer has the worst prognosis of all gastrointestinal malignancies. Lymph node metastasis is a powerful determinant of prognosis. The ratio between the number of affected lymph nodes and the total number of examined lymph nodes is known as lymph node density (LND). LND has proved clinically important in other gastrointestinal malignancies. Our main objective was to identify the role of LND in the prognosis of patients after pancreatic cancer resection. Patients and methods Our study included 30 patients who underwent pancreatic cancer resection from 2010 to 2015. Pathological reports and medical records were retrieved retrospectively for tumor-specific data and patient-specific data (age, sex, and presence of diabetes mellitus). LND was calculated as the number of metastatic lymph nodes divided by the total number of lymph nodes examined. Survival time was calculated from the date of operation to the date of death. Results Patients with LND less than 0.2 have a probability of 1-year survival of 98% and 3-year survival of 62%, which is better than those with LND more than 0.2 (P=0.001). Conclusion LND was significantly related to survival outcome after pancreatic cancer resection, as patients with LND more than or equal to 0.2 displayed a poor prognosis.
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	Cholecystectomy versus percutaneous cholecystostomy drainage in critically ill patients with acute calculous syndrome: a comparative study	p. 46
	Amro El Hadidi, Ahmed Negm, Mohamed Abdel Halim, Magdy Basheer, Mohamed Samir, Mohamed S.A Attia DOI:10.4103/ejs.ejs_104_18   Background Acute calculous cholecystitis is a common disease presentation in critically ill patients. It is associated with increased mortality and morbidity rates in case of insufficient treatment. However, the best approach to management is still debatable. Patients and methods This is a retrospective analysis of prospectively designed study for the evaluation of different management planes in critically ill patients presented with acute cholecystitis in a single university hospital from 2013-2017. The study included all patients with acute cholecystitis as the main reason for patient deterioration and hospital admission and also those patients already admitted in hospital ICU and consulted other departments for symptoms of acute cholecystitis. Preoperative data and operative outcomes were analyzed. Results A total of 225 patients (median age68 years; range=57–91 years) were included. Overall, 28.9% (65 patients) underwent percutaneous cholecystostomy drainage (PCD), 34.2% (77 patients) underwent open cholecystectomy (OC), and 36.9% (83 patients) underwent laparoscopic cholecystectomy. The patients' demographics were comparable in all groups, except for age and BMI. Laparoscopic cholecystectomy was successful in 85.5% of patients. Nine patients in PCD group needed completion OC (13.8%). Preoperative comorbidities were similar in the studied groups. The postoperative infection was high in OC group (P=0.013). The overall mortality was 4%, with the highest value in the PCD group, and no significant difference was observed among all groups (0.197). Hospital and ICU stays were increased in the OC group (P=0.001). Conclusion Open and laparoscopic approaches are safe in critically ill patients and have comparable results to PCD. The advantage of disease eradication cannot be overlooked. The laparoscopic approach is better in the view of short hospital stay and infection rate.
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	Surgical repair of umbilical hernia in cirrhotic patients with ascites: is it safe?	p. 52
	Ahmed A.F Elshoura, Tamer A Elbedewy DOI:10.4103/ejs.ejs_110_18   Background Umbilical herniorrhaphy in cirrhotic patients with ascites is not usually done due to high postoperative morbidity and mortality rates. However, recent reports recommending elective surgery in these patients with perioperative preparation will result in good and safe outcome to avoid emergent repair later on. The aim of this study was to evaluate the outcome of umbilical herniorrhaphy in patients with liver cirrhosis and ascites regarding postoperative morbidity and mortality. Patients and methods A retrospective study was done on 102 patients with umbilical hernia and ascites in the period between March 2014 and April 2017 who had undergone surgical repair either electively or emergently at Tanta University Hospital. Patient characteristics, morbidity, and mortality are recorded. Results Seventy-two men and 30 women with a mean age of 51.3 years were analyzed. Eighteen (17.6%) patients were of Child–Pugh–Turcotte (CPT) class A, 54 (53%) patients were of class B, and 30 (29.4%) patients were of class C. The patients had a model for end-stage liver disease score of 16.23. Fifty-seven patients underwent elective operations while 45 patients underwent emergency surgery of whom 24 patients had incarceration, 12 cases had rupture of the hernia sac, and nine cases had skin ulceration or necrosis. Primary repair was done in 60 (58.8%) patients and meshes were used in 42 (41.2%) patients. The morbidity and mortality rates were 37.2% (n=38) and 3.9% (n=4), respectively. Conclusion Elective repair of umbilical hernia can be performed easily and safely in cirrhotic patients with ascites with good perioperative preparation with better results than emergent repair.
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	Laparoscopic management of large common bile duct stones via choledochotomy	p. 58
	Mostafa Refaie Elkeleny DOI:10.4103/ejs.ejs_111_18   Introduction Choledocholithiasis is a common complication of cholecystolithiasis. Treatment is advisable to prevent further complications. The optimal treatment for common bile duct (CBD) stones is still unclear, but with advances in laparoscopic instrumentation and acquisition of advanced laparoscopic skills, laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis is increasing in popularity among surgeons worldwide. LCBDE can be performed transcystic or by direct choledochotomy. Laparoscopic transcholedochal CBD exploration is preferable since it provides complete access to the ductal system. The aim The aim of this clinical study is to assess the feasibility, advantages, and complication of laparoscopic management of large CBD stones via choledochotomy. Patients and methods This study included 20 cases with large CBD stones of 10 mm or more. LCBDE transcholedochotomy was done in all cases. Results Twelve cases were closed over T-tube, six cases were closed primarily, and bilioenteric anastomosis was done in one case. The mean operative time was122.5±28.2 min and the mean postoperative hospital stay was 6.30±3.7. Conversion occurred in one case. Conclusion LCBDE transcholedochotomy is a feasible, safe, and cost-effective procedure in patients with large CBD stones.
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	The suitable time of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in gallstone-disease-associated choledocholithiasis	p. 63
	Muhammad A Baghdadi, Abd-Elrahman M Metwalli, Fady M Habib, Emad Abdel-Hamid Moustafa DOI:10.4103/ejs.ejs_114_18   Purpose To establish the feasibility, complications, and outcome of different time intervals between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) in the management of choledocholithiasis. Patients and methods This study was carried out on 60 patients who were randomized by systematic randomization into three equal groups according to the interval between ERCP and LC defined as short (3 days or less), medium (4–60 days), or long (60 days or more). All patients have undergone ERCP with sphincterotomy followed by elective LC. Patients' age, sex, history of previous acute cholecystitis, acute pancreatitis and jaundice, abdominal ultrasonography findings, serum bilirubin, alkaline phosphatase, gamma-glutamyl transferase levels, ERCP findings, time interval between ERCP and LC, conversion rate, median operative time, intraoperative complications, hospital stay, and postoperative complication rates were collected. Results There was no statistically significant difference between the demographics of the patients, the preoperative history, laboratory data or ultrasonographic findings in the three groups. The density of encountered adhesions intraoperatively, median operation time, and median postoperative hospital stay in groups 2 and 3 were significantly higher than those of group 1. Other intraoperative and postoperative complications or conversion showed no statistically significant difference. Conclusion Early cholecystectomy after ERCP within 72 h has better outcomes, probably due to less inflammatory processes following ERCP than in groups II and III.
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	Testicular arterial supply: effect of different varicocelectomy approaches	p. 70
	Adel Shehata, Amr Elheny, Alaa M El-Sewaify DOI:10.4103/ejs.ejs_115_18   Aim The aim was to compare the effect of three different approaches of varicocelectomy (laparoscopic, open, and microscopic) on testicular artery depending on preoperative and postoperative testicular duplex. Patients and methods This study included 60 patients with primary varicocele collected from Minia Health Insurance and Minia University Hospitals during the period from April 2016 to January 2018. The patients were divided into three groups. Group A included 20 patients who have undergone open varicocelectomy; group B included 20 patients who have undergone open subinguinal varicocelectomy with microscopic assistance; and group C included 20 patients who have undergone laparoscopic varicocelectomy. Results There is a significant difference between the three groups as regards operative time. Preoperative and 6-month postoperative semen analyses were improved after surgery but no couple achieved spontaneous pregnancy within the follow-up in all three groups. At 2 weeks postoperative arterial duplex, the testicular artery and the testicular arterial perfusion was not affected or disturbed. There was no statistically significant difference between preoperative and postoperative values of testicular volume. No recurrence after 6 months follow-up was found in both A and B groups, but in group C 20% of cases was recurrent clinically. Conclusion No single method has proven superiority over another as the best approach to secure testicular blood supply. We found that there is no statistical difference between the three approaches concerning preservation of the testicular artery from accidental injury or ligation.
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	Schematic algorithm for surgical treatment of idiopathic granulomatous mastitis using combined steroids and therapeutic mammoplasty techniques	p. 79
	Wagdy I Fayed, Khaled E Soliman, Yaser H Ahmed, Mohamed M Alhashash, Kareem A Elayouty DOI:10.4103/ejs.ejs_117_18   Introduction Idiopathic granulomatous mastitis (IGM) is a rare, benign, chronic, inflammatory lesion of the breast of unknown etiology. Clinically, it can be mistaken for inflammatory and neoplastic disorders of the breast. Laboratory investigations with culture and sensitivity, PCR for Mycobacterium tuberculosisand core needle biopsy are crucial. Treatment is controversial, but oral steroids are usually started with, followed by surgical resection if there is no complete response. Aim This study discusses the use of therapeutic mammoplasty techniques to excise the mass and preserve breast aesthetic appearance concerning patient satisfaction and recurrence. Patients and methods Fifty IGM patients were included with moderate to large breasts with masses 20–50% of the breast size after failure of medical treatment with prednisolone, or occurrence of therapy-related complications. Preoperative core needle biopsy, smear for Ziehl–Nelseen acid fast staining, and culture and sensitivity test. Mammography and ultrasonography were done. An informed consent was obtained regarding the operative procedure and research. On surgery we excise the inflammatory mass with a rim of normal nonaffected tissues around with most of retroareolar duct system. Patients were followed up for 1 year in regular outpatient visits, where recurrence and patients' satisfaction were assessed. Results The most important postoperative complication was disease recurrence (4%) and deformity (10%). The most common one was minor wound dehiscence (40%). For patient satisfaction, the median mean percent satisfaction score was 74.50%. Conclusion The use of therapeutic mammoplasty in surgical management of IGM has low recurrence rate and high postoperative patient satisfaction.
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	Randomized, comparative study between using harmonic scalpel with monopolar cautery versus cavitron ultrasonic surgical aspirator with bipolar cautery in liver resection	p. 87
	Mohamed A Naga, Hatem Sayed DOI:10.4103/ejs.ejs_118_18   Introduction Over the last two decades, many studies have been done to assess the best technique and device for liver resection. On a trial to solve this issue, we conducted this study. Materials and methodsStarting from January 2017, 60 patients underwent formal hepatectomies in Ain Shams University Hospitals using two different devices. A total of 30 patients with a mean age of 43 years underwent hepatectomy using cavitron ultrasonic surgical aspirator (CUSA) and the other 30 patients with a mean age of 45.53 years by using the harmonic scalpel. As for the sex, the women were more than men in the harmonic group (n=23 of 30) while in the CUSA group they were less (n=10 of 30). All patients underwent formal hepatectomies; in the CUSA group the majority had right hepatectomy (n=16 of 30) while in the harmonic group the majority had left hepatectomy (n=18 of 30). Results In the CUSA group, the mean operative time was 226.93 min and the resection time was 117.77 min while in the harmonic group, the mean operative time was 202.33 min and the resection time was 102.5 min. In the CUSA group, the mean amount of blood loss was 736.67 ml and the mean blood transfusion was 3.17 units of Packed red Blood Cells (PRBCs), while in the harmonic group, the mean amount of blood loss was 516.67 ml and the mean blood transfusion was 2.57 units of PRBCs. In the CUSA group, 11 patients suffered from postoperative bleeding and seven patients had abdominal hematoma by ultrasound and four patients needed reexploration. In the harmonic group, four patients suffered from postoperative bleeding and one patient had abdominal hematoma by ultrasound and one patient needed reexploration. Conclusion In our study, apart from the biliary complications, we believe that harmonic scalpel is faster and safer than the cusa. Yet another study should be conducted to assess the safety and efficacy of using both devices in combination.
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	Outcomes of an enhanced recovery program after colorectal surgery: a single-center experience	p. 95
	Mostafa Abdo, Kamal Mamdouh DOI:10.4103/ejs.ejs_120_18   Background Successful care of postoperative patients is dependent on optimal nutritional supports, which enhance wound healing and immune response. Enhanced recovery program (ERP) after surgery employs a multimodal perioperative care pathway with the aim of improving the stress response to surgery and outcomes across a range of participation from the patients, surgeons, anesthesiologists, pain specialists, and nursing staff. Objective The aim was to evaluate the outcome of fast-track rehabilitation program versus delayed oral feeding, regular forms of mobilization, and pain control in patients who underwent colorectal surgery. Design This is a prospective study. Patients and methods The present study included 60 patients who were admitted to the Ain Shams University Hospitals between September 2014 and April 2016. We prospectively compared 30 patients: group A submitted for ERP with 30 patients and group B submitted for conventional rehabilitation program for patient outcomes as regards hospital stay, rehabilitation, hospital readmission, and complications. Results Postoperative vomiting in group A occurred in eight (26.7%) patients, while 17 (56.7%) patients in group B without statistical significance, similar was the case with abdominal distention. The overall compliance in group A was better than in group B. Regarding pain control, only nine patients were in need for additional analgesia, while in group B no one was pain free, so additional analgesia was needed in 11 patients. During the hospital stay, only pulmonary complications and hypokalemia were statistically significant between the two groups (P=0.001 and 0.003, respectively). In group A, the mean total postoperative hospital stay was 4.2±1.56 days while in group B it was 8.4±1.6 days (P=0.0001). Conclusion ERP is safe and tolerable after colorectal surgery with no increase in postoperative morbidity and mortality. ERAS protocols should be implemented as the standard approach for perioperative care in colorectal surgery.
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	Short-term outcome of suture rectopexy in children with rectal prolapse: laparoscopic versus posterior sagittal approach	p. 106
	Ahmed H Morsi, Wael Elshahat, Hesham Kassem, Tarek A Gobran, Ismail M Tantawy, Amira H Waly DOI:10.4103/ejs.ejs_130_18   Context Innumerable surgical options addressing persistent rectal prolapse are available. This study compared the short-term outcome of laparoscopic suture rectopexy (LSR) with posterior sagittal rectopexy (PSR). Patients and methods A prospective randomized study was carried out on patients requiring rectal prolapse surgery. Patients were randomly allocated into LSR and PSR groups. Patients with neurological/musculoskeletal deficits, lower gastrointestinal tract anomalies and those with previous pelvic or perineal surgeries were excluded. Results A total of 66 patients, who had suture rectopexy done, were followed up for a minimum of 6 months following surgery. There were 33 LSR and 33 PSR. The mean duration of symptoms was 19 months (range: 6 months to 7.5 years). The mean age at operation was 5.9 years (range: 2.5–12 years), with a slight female predominance (54.5%). The mean operative time was 87.2 and 51.3 min for LSR and PSR, respectively. The mean postoperative hospital stay was 41.18 and 31.87 h for PSR and LSR, respectively. LSR had better Manchester Scar Scale scores compared with PSR (mean: 6.45 and 10.09, respectively). LSR patients resumed unrestricted activities earlier than those of PSR (mean: 9.84 and 15.15 days, respectively). Both groups showed comparable improvements in bowel functions and quality of life. Complications were a transient partial recurrence in one LSR patient (3.1%) and two wound infections in PSR group (6.2%). There was one conversion to laparotomy in LSR group (3.1%). Conclusion Both techniques seemed equally effective in eliminating rectal prolapse. Without longer operative times and conversion to laparotomy, LSR would have been absolutely superior to PSR.
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	The incidence of metastases to facial lymph nodes in patients with carcinoma of head and neck	p. 113
	Ahmed F El-Kased, Hossam Abd El-Kader El-Fol, Mohamed M Ahmed El-Elaimy, Mohamed Sabry DOI:10.4103/ejs.ejs_134_18   Background and objective Supramandibular facial lymph nodes (SFLNs) are one of the unusual sites of lymph nodes metastases. This prospective study investigated the possible involvement of SFLNs in cases of head and neck carcinoma. Patients and methods SFLNS were identified and dissected from 30 neck dissections obtained from 30 patients (22 male individuals and eight female individuals) with squamous cell carcinoma (SCC) of the oral cavity without locoregional recurrence or distant metastases.Result Histopathological examination of the removed SFLN nodes proved positive for metastases in nine neck dissections, five cases of buccal mucosa SCC (41.7% of the cases) and four cases of alveolar margin SCC (44.4% of the cases). Conclusion SFLNs are a probable site of lymph node metastases in SCC of the alveolar margin and buccal mucosa. Careful dissection above the lower margin of the mandible can safely remove these nodes without significant injury to the marginal mandibular branch of the facial nerve.
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	Extraordinary approaches for treatment of complex tibial and popliteal arterial occlusions	p. 120
	Mohamed E Elsherbeni, Abdelrahman M Gameel, Waleed A Sorour, Amr Elboushi, Ayman Salem DOI:10.4103/ejs.ejs_144_18   Objective The purpose of this study is to evaluate the efficacy and safety of different tibiopedal approaches as alternative methods for failed antegrade recanalization of popliteal and infrapopliteal arterial occlusions. Patients and methods A prospective study was done at Vascular Surgery Department, Zagazig University Hospitals, from February 2015 to June 2018. During this period, 73 patients with critical lower limb ischemia with popliteal and/or infrapopliteal lesions underwent endovascular intervention. Antegrade recanalization failed in 17 patients (nine males and eight females with the mean age 68.6±9.8 years). Retrograde tibiopedal approach was tried in them. Six patients were Rutherford category 4 (complaining of rest pain), eight patients were Rutherford category 5 (had ischemic ulcers), and three patients were Rutherford category 6 (had gangrene). The mean ankle brachial index was 0.39±0.11. Three patients had occlusions in the popliteal artery only, 11 patients had tibial occlusions, and three patients had combined popliteal and tibial occlusions. The mean length of lesions was 9.7±2.8 cm. Eleven (64.8%) patients had Trans-Atlantic Inter-Society Consensus II C lesions and six (35.2%) patients had Trans-Atlantic Inter-Society Consensus II D lesions. Results We succeeded in 13 (76.5%) patients to cross the occlusion and recanalyze the target vessel [completing the procedure from the antegrade approach in eight (47.1%) patients, and completing the procedure from the retrograde approach in five (29.4%) patients]. The mean ankle brachial index was improved significantly from 0.39±0.11 before to 0.78±0.12 after the intervention (P<0.01). Conclusion Retrograde tibiopedal approach can be used safely as a bailout to increase the technical success rate and limb salvage for failed antegrade recanalization of popliteal and infrapopliteal arterial occlusions.
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	Safety and efficacy of sirolimus in patients with refractory vascular anomalies	p. 127
	Ahmed Abdelhaseeb Youssef, Mohamed S Mostafa, Ahmed Fawzy, Wael M.A Elzeneini, Mohamed M.D Aly, Mohamed H Soliman, Mohammed Abdel-Latif, Mohamed Abdelsattar, Eman Ragab, Hesham M Abdel-Kader DOI:10.4103/ejs.ejs_145_18   Background Vascular anomalies are a heterogeneous group of anomalies. The majority follow a benign course. However, some, for example, kaposiform hemangioendotheliomas, may be life threatening. Many lines of treatment have been described; however, no single agent is always successful. It has been suggested that Mammalian Target of Rapamycin (mTOR) inhibitors such as sirolimus could be beneficial.Patients and methods Twelve patients with different vascular malformations refractory to different modes of treatment presented to our vascular malformations clinic, including three patients with Klippel-Trenuany Syndrome, three with kaposiform haemangioendothelioma, two with hereditary hemorrhagic telangiectasia, two with Parkes Weber syndrome, and two with lymphatic malformations. The patients were clinically examined, and them and their caregivers were asked to fill the pediatric quality-of-life inventory version 4.0 (pedsQL Generic Core Scale). Then they were put on oral sirolimus 0.8 mg/m2adjusted to achieve serum level 10–15 ng/ml. Participants were followed up prospectively and asked to fill the quality-of-life assessment form once more after 12 months. Results Mean age of participants was 7.9 years with female predominance (8/12). Mean duration of treatment was 14.6 months. All the 12 patients significantly improved on sirolimus regarding quality-of-life score and symptoms. Conclusion Sirolimus is a valid and safe option in the treatment of refractory vascular malformations.
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	Application of cyanoacrylate for mesh fixation in open inguinal hernia repair	p. 131
	Abdelmoniem I Elkhateeb, Gamal A Makhlouf, Ragai S Hanna, Mahmoud S Aly, Adel M Shehata DOI:10.4103/ejs.ejs_148_18   Aim This work aimed to identify the outcomes of mesh fixation using cyanoacrylate in open inguinal hernia repair with regard to long-standing groin pain, operative time, rate of recurrence, degree of postoperative pain, and other complications. Patients and methods This was a prospective cross-sectional analytic study on 54 patients complaining of unilateral inguinal hernia that evaluated the usage of cyanoacrylate in open inguinal hernioplasty as a material for mesh fixation. The study was conducted in the General Surgery Department between November 2016 and February 2018. Male patients with denovo unilateral inguinal hernia suitable for elective open mesh repair were involved in the study and gave informed consent. Follow-up was carried out during a period ranging from 1 to 6 months. The primary outcome was early complications including early postoperative pain, bleeding, infection, seroma, and operative time. Secondary endpoints were long-standing groin pain and recurrence rate. ResultsAbout 48 cases of 54 (88.9%) needed less than 4 min for mesh fixation in open inguinal hernia repair. An overall 44% of cases have reported no early postoperative pain. Only 5.6% of cases have reported a status of chronic groin pain, and no cases have been reported for recurrence. Conclusion The results have led us to recommend the usage of cyanoacrylate for fixation of mesh in inguinal hernia repair to decrease the occurrence of postoperative complications in inguinal hernioplasty, generally, and the long-standing groin pain particularly, especially in patients who are more prone to experience pain.
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	The 1470 radial endovenous laser ablation of the great saphenous vein larger than 12 mm: is it a good option? A single-center experience	p. 136
	Amr Elboushi, Mohamed Elsherbeni, Abdelrahman M Gameel, Waleed Sorour, Mohamed Amin, A. Samir, A. Salem DOI:10.4103/ejs.ejs_150_18   Introduction Endovenous ablation of varicose veins has been used to treat varicose veins and has gained popularity as one of the preferred techniques to treat axial reflux. Initially the diameter recommended was less than 8 mm, then gradually surgeons starting gaining the experience to treat larger veins. Treating larger veins has been on the controversial side with some surgeons recommending surgery versus others recommending endovenous ablation. Patients and methods The patients were divided to three groups according to the great saphenous vein diameter and follow-up duplex arranged at 3, 6, and 2 months. Visual analog scale was used at 1 week and 4 weeks to assess postoperative pain.Results In our study, there was no incidence of deep venous thrombosis (DVT) or nerve injury in any of our groups. At 1 month, there was significant difference between the groups, but at 4 weeks there was no significant difference regarding postoperative pain. There was no recanalization with an occlusion percentage of 100% in the 3-month duplex scan in all the groups. There is no significant statistical difference between the groups regarding recanalization at 6 and 12 months. Conclusion Our study showed good short-term results of endovenous laser therapy in the ablation of large-diameter great saphenous vein. The use of endovenous laser therapy has to be a dynamic process where you as an endovascular surgeon can change a variety of parameters to optimize the final results of the procedure.
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	Dual stenting for both CBD and duodenum versus surgical bypass in the management of advanced head of pancreas cancer	p. 142
	Mostafa M Elaidy, Mohamed Farouk, Ahmed Yahia DOI:10.4103/ejs.ejs_152_18   Background As 70–90% of patients with carcinomas of the head of the pancreas and ampullary region have jaundice at presentation and going to have gastric outlet obstruction, palliation that ensures biliary and gastric drainage represents a large proportion of the hepatobiliary surgeon's workload. As barely 20% of patients with pancreatic cancer are suitable for curative resection, good palliative therapy is extremely important. Aim of the work To compare the effectiveness of palliation between patients with advanced head of pancreas cancer who underwent surgical bypass and those who underwent dual stenting and morbidity and mortality rates of both procedures. Patients and methods This prospective study was conducted between April 2015 and April 2017. Only 38 patients were eligible for this study. Follow-up was at 1, 3, and 6 months after each procedure. Evaluation of patients regarding efficacy and feasibility, morbidity, mortality, hospital stay, ICU admission, readmission rate, and survival was done.Results We identified 38 patients, of whom 19 underwent endoscopic stenting and 19 underwent a surgical bypass either by choledechojejunostomy or cholecystojejunostomy-en-Y with gastrojejunostomy. There were no significant differences in complications or mortality rates; however, all results were in favor of dual stenting, owing to short procedure time, hospital stay, ICU admission, and survival rates being better than surgical bypass, although without significance. Conclusion Dual stenting was found to be more feasible and efficient in palliation of advanced head of pancreas cancer with short procedure time and short hospital stay and less morbidity and mortality and ICU admission with higher cost in comparison with surgical bypass. Surgical bypass is mandatory in patient with gastric outlet obstruction or failed Endoscopic Retrograde Cholangiopancreatography (ERCP) trial due to huge mass obstructing the duodenum.
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	Impact of neoadjuvant chemoradiation on pathologic response and survival of patients with rectal cancer	p. 155
	Ahmed F Elkased, Nancy Y Asaad, Naser M Abd Al-Bary, Mohamed S Amar, Mohamed B Elgezawy DOI:10.4103/ejs.ejs_163_18   Objectives The aim of this study was to assess the impact of neoadjuvant chemoradiation on the pathologic response and survival of patients with rectal cancer. Background Colorectal cancer is one of the most common human malignancies; there are a number of potential advantages for using neoadjuvant chemoradiation. They include the ability to deliver higher doses of chemotherapy with radiation, downstage the tumor, which has been noted in 60–80% of patients, and to achieve a pathologic complete response, which occurs in 15–30% of patients. The ability to 'shrink' the tumor facilitates surgical resection and performs a sphincter-preserving operation, radiating tissues with a greater oxygen supply, and decreases the likelihood of developing radiation enteritis, because the small bowel is less likely to enter the pelvis. Patients and methods This study included 80 patients with operable cancer rectum. A total of 40 randomized patients were treated with neoadjuvant chemoradiotherapy (CRT) followed by surgery, and the other 40 patients underwent surgery without neoadjuvant CRT. The pathological response to neoadjuvant CRT with regard to tumor necrosis, size, negative margins, number and size of lymph nodes with operative findings with regard to resectability and blood loss were assessed and then the follow-up of patients was carried out and compared with another group. Results We detected a statistically significant difference between both groups with regard to some pathological responses, including grade of tumor differentiation, number and positivity of lymph nodes, perioperative complication, and disease-free survival but no difference in overall survival. Conclusion Neoadjuvant chemoradiation could affect the disease-free survival of patients with rectal carcinoma.
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	Ligation of intersphincteric fistula tract technique in the management of anorectal fistula	p. 160
	Muhammad A Baghdadi, Abd-Elrahman M Metwalli DOI:10.4103/ejs.ejs_171_18   Background and aims Anorectal fistula is one of the most common problematic anal conditions in daily surgical practice. Many treatment modalities are used. This study evaluates the ligation of intersphincteric fistula tract procedure on the basis of its postoperative outcomes. Patients and methods This study was carried out on 25 patients. Participants of either sex diagnosed with anal fistula (transsphincteric fistula, either high or low) were included in the study between April 2016 and May 2018. Patients with recurrent fistulas, Crohn's disease, and anal or distal rectal cancers were excluded from the study. Results The mean age group of the study participants was 36.6±8.34. The sex distribution showed a higher number of men (n=17) compared with women (n=8). The mean operative time was 35.46±3.6 min and the mean healing time was 6 weeks. Anal incontinence was not observed (0%). A total of two (8%) participants developed recurrence. Conclusion The Ligation of intersphincteric fistula tract procedure is an effective and sphincter-preserving technique for fistula-in-ano with a shorter healing time and a lower incidence of recurrence.
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	Impact of negative pressure wound therapy in complete healing rates following surgical debridement in heel and ankle regions in diabetic foot infections	p. 165
	Ayman Hasaballah, Hesham Aboloyoun, Ahmed Elbadawy, Manal Ezeldeen DOI:10.4103/ejs.ejs_180_18   Aim The aim was to evaluate 120-day complete wound healing rates in negative pressure wound therapy (NPWT) versus conventional dressings in anatomically challenging areas (the heel and ankle regions).Patients and methods A retrospective, cohort study that included diabetic patients having acute (<30 days) challenging wounds at the area of the heel and ankle after surgical debridement and achieved complete wound healing or 120-day follow-up whichever occurs first. Forty-four patients were identified and were divided into two groups according to the method of wound therapy. Group A (NPWT, n=18) and group B (conventional moist daily dressings, n=26). The primary end point was complete wound healing rates within 120 days. Distribution of characteristics between study groups and healing rates among different risk groups were reported. Kaplan–Meier curve on the basis of time-to-event strategy followed by a log rank test to measure difference among study groups were performed. Results Complete wound healing within a 120-day assessment period was achieved in 72.3% (group A) and 30.8% in group B (P=0.019). There was no overall significant difference in the distribution of characteristics among two groups except for BMI (P=0.03) and albumin level (0.02). However, HgA1c levels (P=0.01) and wound treatment method (P=0.007) were only factors that significantly affected the healing rate. Conclusion On the basis of current data analysis, the use of NPWT should be recommended for acute diabetic foot wounds in the heel and ankle regions to obtain faster complete healing and desired wound closure in such critical areas.
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