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   2015| January-March  | Volume 28 | Issue 1  
    Online since April 29, 2015

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Treatment of humeral shaft fractures by a single elastic stable intramedullary nail in children
Ahmad Abd El-Azeem Abosalim, Ahmad Fouad Shams El-Din, Hesham Mohammed El-Mowafy
January-March 2015, 28(1):125-132
Objective The aim of this study was to assess the effectiveness of intramedullary fixation of displaced humeral shaft fractures in skeletally immature children using a single elastic stable intramedullary nail. Background Almost all pediatric humeral shaft fractures can be treated successfully using closed methods. Some patients, however, require internal fixation either because of an inability to maintain an adequate reduction, significant soft tissue injury, or concomitant fractures. In this study, the functional and radiological results of the management of humeral shaft fractures in children using a single retrograde elastic intramedullary nail will be evaluated. Patients and methods Twenty pediatric patients ranging in age from 6 to 16 years (mean age 10 years) were treated surgically using a retrograde single elastic intramedullary nail. Relative surgical indications included open fractures, inability to maintain an acceptable reduction, concomitant lower extremity fractures, and closed head injury. Two patients had associated radial nerve injury at presentation. Among the patients, 16 were males and four were females. Results The patients were followed for a mean of 5.5 months, with a range from 4 to 6 months. Radiographically, all fractures healed in good alignment. Solid union occurred from 5 to 10 weeks, with a mean of 8 weeks. There were no intraoperative complications, including neurologic or vascular injury, and two patients developed superficial wound infections postoperatively. Conclusion It was found that single elastic intramedullary nail fixation with the aid of a functional arm brace is an adequate technique for the treatment of humeral shaft fractures in pediatric patients when surgical stabilization is indicated. This simple minimally invasive technique provides stable fixation, with minimal soft tissue stripping at the fracture site, and led to bone union in all the cases studied. Level of evidence Case series, level IV.
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Minimally invasive plate osteosynthesis versus open reduction and plate fixation of humeral shaft fractures
Mahmoud Mohamed Hadhoud, Amr Eid Darwish, Mustafa Mohamed Kamel Mesriga
January-March 2015, 28(1):154-161
Objective This study compared clinical outcomes and complications in patients with humeral shaft fractures treated using two methods of fixation by means of plating. Background Plate osteosynthesis has been the treatment of choice for humeral shaft fractures when operative treatment is required. However, plate osteosynthesis of comminuted humeral fractures is a challenging operation, which requires surgical experience and meticulous attention to soft tissue. Minimally invasive plate osteosynthesis (MIPO) is an emerging procedure for the treatment of humeral shaft fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing. Patients and methods Thirty patients were analyzed and divided into two groups. Group 1 (n = 15) patients were treated with MIPO and group 2 (n = 15) with open reduction and internal fixation (ORIF). The major characteristics of the two groups in terms of age, sex, mode of injury, fracture location, and associated injuries were similar. Results Primary union was achieved in all patients in the MIPO group and in 14 of 15 in the ORIF group. The mean time to union was similar in the two groups. The mean operation time in the MIPO group (80 min) was shorter than that in the ORIF group (125 min) (P < 0.0001). Bone grafting was performed in one patient in the ORIF group, but in no patients in the MIPO group. There was one case of deep infection in the ORIF group. There was one case of postoperative radial nerve palsy in the MIPO group and two cases in the ORIF group. Functional outcome was satisfactory in both groups. Conclusion The MIPO technique achieves comparable results with the ORIF method in simple and complex fractures of humeral shafts. Although MIPO potentially has a radiation hazard, it reduces perioperative complications with shortened operation time and minimal soft tissue dissection.
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Laparoscopic versus open repair of perforated duodenal peptic ulcer: a randomized controlled trial
Adel S Zedan, Magdi A Lolah, Mohammed L Badr, Mohammed S Ammar
January-March 2015, 28(1):62-68
Objective The aim of this study was to compare between laparoscopic and laparotomy repair of perforated duodenal ulcer in terms of operative time, postoperative pain, postoperative complication, hospital stay, and resuming normal activity. Background Laparoscopic surgery has become a standard of care in many of the elective procedures; however, it is still gaining popularity in conditions associated with peritonitis, such as perforated duodenal ulcer. Materials and methods This is a prospective study that included 50 patients with perforated duodenal peptic ulcer admitted to the General Surgery Department in Menoufia University Hospitals from October 2012 to April 2014. The patients were divided by random serial number method into two groups: group A consisted of 25 patients for laparoscopic procedure, and group B consisted of 25 patients for open repair. Results In group A, 21 patients underwent successful laparoscopic surgery, and four patients were converted to laparotomy, and in group B, 24 patients were evaluable, and one patient died on the fourth postoperative day not related to surgical cause. Operating time was significantly longer in the laparoscopy group, 145 ± 8.4 versus 110 ± 13 min. Patients who underwent laparoscopic repair were associated with lower morbidity, with P-value less than 0.05. No significant difference was found regarding leak or intra-abdominal abscess. Hospital stay was significantly shorter in the laparoscopic group, 6.9 ± 2.2 versus 8.9 ± 3.3 days. Patients who underwent laparoscopic procedure resumed normal activity earlier than the patients in the laparotomy group, 14 ± 1.9 versus 20.5 ± 3.9 days, with P-value less than 0.001. Conclusion Laparoscopic correction of perforated peptic ulcer causes less postoperative pain, postoperative complications, and hospital stay.
  2 1,633 197
Scheimpflug camera changes after cross-linking for keratoconus
Abdel Khalek Ibraheem El Saadany, Mohamed Saad Al-Balkini, Moataz Fayez Abdel Hameed El Sawy, Mark Frederic Berge Ananian
January-March 2015, 28(1):168-173
Objectives The aim of our study was to evaluate corneal changes after corneal collagen cross-linking (CXL) in progressive keratoconus with Pentacam Scheimpflug imaging. Background Corneal collagen CXL using ultraviolet A light and riboflavin was introduced as a method to halt the progression of keratoconus. Scheimpflug imaging is considered among the most prevalent modalities in the diagnosis, staging, and follow-up of keratoconus patients. Materials and methods This study was a prospective interventional study that included 23 eyes of 18 patients with a mean age 23.39 ± 5.83 years with keratoconus. All underwent corneal collagen CXL using riboflavin and ultraviolet A light. Uncorrected visual acuity and best-corrected visual acuity were assessed. Pentacam's K1 , K2 , thickness at thinnest corneal point, anterior corneal elevation, posterior corneal elevation, cylindrical power and axis, and aberration coefficient were all determined before CXL, 3, and 6 months after CXL. Results There was improvement of uncorrected visual acuity from 0.16 ± 0.2 to 0.24 ± 0.21 (P = 0.001) and best-corrected visual acuity from 0.46±0.19 to 0.63 ± 0.24 after 6 months (P < 0.001). Significant decreases after 6 months were found in keratometry values: K1 from 47.69 ± 4.02 to 47.04 ± 4.43 D (P = 0.004) and K2 from 51.74 ± 4.76 to 51.03 ± 4.92 D (P < 0.001). In addition, there was decrease in thickness at thinnest corneal point from 448.04 ± 32.3 to 438.35 ± 35.42 mm (P = 0.025), anterior elevation from +34.17 ± 13.6 to +30.65 ± 11.11 mm (P = 0.06), and posterior elevation from +74.04±25.71 to +67.39 ± 23.09 mm (P = 0.03). Corneal cylinder and aberration coefficient showed stability with no significant change. Conclusion There is increasing evidence that CXL does not only halt the progression in the keratoconic eye by corneal tissue strengthening, but also improves visual outcomes and corneal shape, which are against the natural course of the disease.
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Comparative study between primary versus delayed peripheral nerve repair after various types of injury
Ashraf Abdulhady Zeineldin, Moharram Abdel Samie Mohammed, Abdel Azim Labib Elhoseny
January-March 2015, 28(1):80-86
Objective The present work was designed to compare primary and delayed peripheral nerve repair after various types of injury. Background Peripheral nerve injures are common and involve the upper and lower extremities. These injuries may cause significant deficits and impaired functional recovery. Median and ulnar nerve injuries are examples of such lesions, occurring as isolated or combined injury of both nerves. In contrast to the central nervous system, peripheral nerves have the ability of regenerating. This ability has been utilized for a long time in the treatment of injuries of peripheral nerves. Patients and methods We studied 30 patients aged 6-60 years (average 28 ± 14 years) presenting to the Emergency Department and Neurosurgery Outpatient Clinic of Shebien El Kom Teaching Hospital with peripheral nerve injury from February 2012 and May 2013. The patients were followed up until July 2013. Sixteen (53.3%) patients underwent primary repair, and 14 (46.7%) were treated with a delayed method. The highest number of nerve injuries was at the wrist level (43.3%); the elbow was injured in 23.3% of patients and the least frequent nerve injuries were in the thigh (6.7%). Results Success was seen in 14 of 16 patients who underwent primary repair and in seven of 14 patients who underwent delayed repair. Excellent results were common in younger patients. Conclusion Recovery following primary repair was faster than in other methods. For reaching excellent results in repairing peripheral nerves, it is important to follow all rules needed for repairing cut peripheral nerves, as well as accurate evaluation and correct repair of injured surrounding soft tissue such as tendons and their synovium and injured vessels.
  1 1,220 118
Surgical outcome of endoscopic versus microscopic trans-sphenoidal approach for pituitary adenomas
Mohamed Ahmed Aly Eltabl, Yousry Mahmoud Eladawy, Adel Mahmoud Hanafy, Essam El-Din Gaber Saleh, Hossam Abdel-Hakeem Elnoomany
January-March 2015, 28(1):87-92
Objective The aim of the study was to compare between endoscopic and microscopic trans-sphenoidal approach regarding surgical outcome and postoperative complications. Background Pituitary adenomas are the third most common intracranial tumors in surgical practice, accounting for ~10-25% of intracranial tumors. These tumors may gain large size before producing hormonal or visual symptoms. There are many surgical approaches for these tumors. Patients and methods Over the last 3 years, 40 patients with pituitary adenoma either microadenoma or macroadenoma were operated through trans-sphenoidal approach either microscopically or endoscopically. Patient consent was obtained followed by careful clinical history, symptoms, signs, and preoperative radiological evaluation. Operative and postoperative events were noted with 3 months follow-up. Results A total of 40 patients with pituitary adenomas were operated trans-sphenoidally. The mean age was 35.9 years (range 21-60 years). The number of men was 23 (57.5%) and women was 17 (42.5%). The most common presenting symptom was headache in 25 (62.5%) patients and visual complaints in 24 (60%) patients. Amenorrhea and acromegaly were in eight (20%) patients for each; Cushing syndrome was present in three (7.5%) patients. Hyperthyroidism and infertility were in two (5%) patients for each. Conclusion Surgical outcome in endoscopic trans-sphenoidal approach is better than microscopic approach regarding postoperative nasal complications.
  1 949 95
Resurrection of the Amsler chart in macular diseases
Moustafa Kamal Nassar, Nermeen Mahmoud Badawi, Mostafa Mohammed M Diab
January-March 2015, 28(1):174-180
Objectives To assess the validity of the Amsler chart as a screening test for the detection of macular diseases and to test its reliability in the follow-up of patients with macular diseases compared with other confirmatory investigative methods such as fundus fluorescein angiography (FFA) and optical coherence tomography (OCT). Background The Amsler chart provides a convenient method to detect and monitor macular diseases on the basis of a grid pattern that allows both scotomas (detected by missing or blurred lines) and metamorphopsia (bowed or distorted lines) to be detected. Since its discovery, the Amsler grid has become important in the evaluation of the central 20° of the visual field surrounding the fixation. Methods A total of 50 eyes of 50 patients with different types of macular diseases were tested by the Amsler chart and compared with other diagnostic investigations (fundus fluorescein angiography and optical coherence tomography) in each patient. These patients were followed at 1, 3, and 6 months by BCVA, the Amsler chart, and other investigations. Results Fifty patients (50 eyes) were analyzed statistically. The sensitivity of detection of macular disease by the Amsler grid was 88% (95% confidence interval: 77.9-97.6%). There was substantial agreement between the results of the Amsler grid and those of other investigations on the follow-up evaluation. Conclusion The Amsler chart is an accurate test in detecting macular disease, and if used properly, it could be effective in the early detection of macular diseases. The Amsler chart could be used for the follow-up of patients suffering from macular diseases with high reliability.
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Immunomodulation in critically ill septic patients
Safaa M Helal, Ghada A Hassan, Sherif I Zalat, Mohamed A Azkol
January-March 2015, 28(1):259-265
Objective To perform a systematic review on previous trials of immunomodulatory therapies, on current therapies trialed previously and on potential therapies for the near future. Data analysis Electronic medical research databases were searched from 1950 or from the starting date of each database. The search was performed on 1 December 2013 and included earlier-published printed articles without language restrictions. Study selection The initial search presented 363 articles, of which 30 met the inclusion criteria. The articles were previous trials of immunomodulatory therapies as well as current therapies trialed previously and potential therapies for the near future. Data extraction The study quality aimed at achieving ethical approval, prospective design, specified eligibility criteria, the use of appropriate controls, adequate follow-up and defined outcome measures. Data synthesis Because of the heterogeneity in follow-up periods and reported outcome measures, it was not possible to pool the data and perform a meta-analysis. Comparisons were made by a structured review. Recent findings Numerous trials have been targeted at inhibiting various essential inflammatory mediators and receptors involved in sepsis. This includes the use of activated protein C, corticosteroids, statins and the inhibition of nitric oxide. Hypertonic saline solution, intravenous immunoglobulins, mesenchymal stem cells and colony-stimulating factors have also been tried. Corticosteroids and activated drotrecogin alfa are to date the only drugs that have demonstrated mortality benefits in large randomized controlled trials. Conclusion Our knowledge of the pathophysiology of the inflammatory response in sepsis continues to expand. Potential new therapies continue to be developed. Enhanced knowledge of the molecular biology of inflammation may result in improved treatment for septic patients.
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Biomarker predictors of survival in patients with ventilator-associated pneumonia
Mohamed H Afifi, Amera A Elhendy, Moataz M Eltaweel, Neven M Soliman, Elham M Elfeky, Asmaa E Salama
January-March 2015, 28(1):254-258
Objective The aim of this study was to determine the role of procalcitonin (PCT) and C-reactive protein (CRP) as predictors of survival in ventilator-associated pneumonia (VAP) and determine the most common micro-organisms involved in VAP in the Menofiya University Hospital ICU. Background The prediction of survival in VAP remains a major challenge. We evaluated the performance of clinical score [Sequential Organ Failure Assessment (SOFA)], PCT, and CRP threshold values and kinetics as predictors of VAP survival. Materials and methods A total of 50 patients with VAP were studied at the Menofiya University Hospital ICU. Acute Physiology And Chronic Health Evaluation II (APACHE II) score was assessed during first 24 h of admission; clinical pulmonary infection score was followed up in mechanically ventilated patients for diagnosis of VAP. SOFA score, serum CRP, and serum PCT were assessed on day 1, day 4, and day 7 of VAP diagnosis and were correlated with the 28-day survival/mortality. Patients who survived were considered survivors (group A), and patients who died before 28 days were considered nonsurvivors (group B). Results The 28-day mortality rate was 40%. The APACHE II score was significantly lower in survivors than nonsurvivors (P < 0.001). Serum PCT was significantly lower on days 4 and 7 in the survivor group (504.87 ± 267.28, 164.30 ± 98.56 pg/l, respectively) in comparison with the nonsurvivor group (930.30 ± 177.54, 897.35 ± 200.99 pg/l) with a P-value of less than 0.001. The SOFA score was significantly lower on days 1, 4, and 7 in the survivor group (5.73 ± 1.80, 4.57 ± 1.22, 3.63 ± 1.16) compared with the nonsurvivor group (7.95 ± 1.39, 8.60 ± 1.53, 9.85 ± 1.90, respectively), with a P-value of less than 0.001. Serum CRP was comparable on days 1, 4, and 7 days in the survivor (108.0 ± 55.93, 103.60 ± 43.69, 85.6 ± 58.68 mg/dl) and the nonsurvivor group (108.0 ± 46.39, 100.80 ± 51.41, 100.80 ± 58.06 mg/dl), respectively. Age was significantly higher in the nonsurvivors than the survivors (61.30 ± 15.60, 46.93 ± 18.25, respectively) (P = 0.002). Conclusion The SOFA score can predict survival in VAP. The serum level of PCT can be used for diagnosis of VAP. PCT kinetics can be used to assess prognosis in VAP patients. CRP is useful as a diagnostic but not as a prognostic biomarker in VAP.
  - 1,018 169
Dead space obliteration for reducing seroma formation after mastectomy and axillary dissection
Alaa A El-Sisi, Abd El-Monem F Mohamed, Naglaa F Amer
January-March 2015, 28(1):69-73
Objective The aim of the study was to detect the efficiency of dead space obliteration to reduce postmastectomy seroma formation, leading to early drain removal. Background Breast cancer is the most common female cancer worldwide. It accounts for 33% of female cancers at the National Cancer Institute (NCI). Primary operable breast cancer can be treated by either modified radical mastectomy or conservative breast surgery. Seroma represents the most important complication after modified radical mastectomy. Patients and methods Forty patients with primary operable breast cancer were included in this study from February 2013 to March 2014. They underwent modified radical mastectomy and were then divided into two groups: group A and group B. In group A patients, the wound was closed by means of the flap-fixation technique by continuous suturing of the upper flap to the pectoralis major muscle and lateral chest wall and suturing the pectoralis major muscle to the pectoralis minor muscle by four to six interrupted sutures using vicryl 2/0. In group B patients, the wound was closed by means of simple closure and application of a crepe bandage. Results There were significant differences between the two groups as regards the total amount of drained serous fluid (P < 0.001) and the duration for drain removal (P < 0.001). The flap-fixation technique shows significant decrease in the number of patients who developed seroma after drain removal (P < 0.001). Conclusion The flap-fixation technique is a valuable technique for reducing seroma formation after mastectomy and axillary dissection.
  - 1,390 144
Free anterolateral thigh flap in head and neck reconstruction
Shawky Shaker Gad, Fouad Mohammed Ghareeb, Yasser Mohammed Elsheikh, Mohammed Abdullah El-Nahas
January-March 2015, 28(1):74-79
Objectives The aim of this randomized prospective trial was to evaluate indications, advantages, disadvantages, and complications of the usage of anterolateral thigh (ALT) flap as a free flap in head and neck reconstruction. Background Reconstruction of the head and neck continues to pose a formidable challenge for maxillofacial and plastic surgeons.The free ALT flap has emerged as a popular option for the reconstruction of head and neck defects. The present study evaluates the usage of free ALT flap in head and neck reconstruction. Materials and methods From January 2012 to January 2013, patients who had extensive soft-tissue defect in the head and neck and had been reconstructed by free ALT flap have been reported. Flap data (type, length, and width), duration of flap elevation, donor-site morbidity, postoperative complications, and follow-up data including aesthetic and functional outcome were recorded. Results The mean total harvest time of the flap was 113 min, the mean skin paddle width in our study was 10 cm (range, 7-15 cm), and length was 13 cm (range, 10-16 cm). The donor site in all cases had been closed directly. Failure of microvascular anastomosis occurred in one flap (from a total of three cases in the study), although no significant donor morbidity has been reported. Conclusion The ALT flap can be reliably harvested without incurring serious donor morbidity. It possesses workhorse attributes (no repositioning, remote from defect, and long pedicle) and is extremely versatile, making it ideal for the heterogeneous group of extensive soft-tissue head and neck defects.
  - 1,863 154
Randomized comparative study of Ligasure versus conventional (Milligan-Morgan) hemorrhoidectomy
Olfat Issa El Sebaei, Alaa Abd El Azeem El Sisi, Mohamed Sabry Amar, Mohamed Ezzat El Sayed
January-March 2015, 28(1):27-33
Objectives The objective of this study was to evaluate the two approaches for hemorrhoid surgery - Ligasure hemorrhoidectomy and conventional (Milligan-Morgan) hemorrhoidectomy - in terms of operative time and blood loss, as well as postoperative pain, bleeding, analgesic requirement, urinary retention, discharge, stenosis, fecal incontinence, wound healing, and patient satisfaction. Background To compare the surgical outcome of hemorrhoidectomy performed using Ligasure bipolar diathermy with conventional hemorrhoidectomy. Patients and methods Twenty patients with grade III or IV hemorrhoids were randomized equally to conventional hemorrhoidectomy (group 1) and Ligasure (group 2) hemorrhoidectomy. Operative details were recorded, and patients recorded daily pain scores on a linear analogue scale. Follow-up was weekly for 2 months and then monthly for 6 months to evaluate complications, return to normal activity, ongoing symptoms, and patient satisfaction. Results The mean reduced intraoperative blood loss (±SD) was 1.2 ± 1.6 ml (ranging from 0 to 5 ml) in the Ligasure group (group 2) versus 22.2 ± 6.58 ml (ranging from 15 to 35 ml) in the conventional group (group 1) (P = 0.0001). The mean operative time in minutes in the Ligasure group was 6.6 ± 4.3 (ranging from 5 to 10 min) versus 21.7 ± 4.3 in the conventional group (ranging from 15 to 26 min) (P < 0.001). There was significant difference in postoperative pain scores and analgesic requirement especially in the first week. Wound healing was excellent in the Ligasure group. There was no difference between the two groups in terms of degree of patient satisfaction and number of postoperative complications. Conclusion Ligasure is an effective instrument for hemorrhoidectomy, which results in lower volume of blood loss, less postoperative pain, quicker wound healing, and earlier return to work.
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Concomitant repair of moderate tricuspid regurge in patients undergoing mitral valve surgery
Ahmed Labib Dokhan, Islam Moheb Ibrahim, Yahia Mohammed Alkhateep, Hany Mehany Mohamed
January-March 2015, 28(1):34-37
Objectives The aim of this study was to evaluate surgical results in patients with moderate tricuspid regurge undergoing mitral valve surgery either with or without concomitant tricuspid repair 6 months after surgery. Background Moderate tricuspid regurge has a variable natural history, as it may regress after mitral valve surgery without tricuspid repair, or may progress; hence, the decision to repair moderate tricuspid regurge in concomitant tricuspid repair with mitral valve surgery remains controversial. Patients and methods This study was conducted from January 2010 to June 2013. A total of 50 patients underwent mitral valve replacement for the first time with concomitant moderate tricuspid valve regurge. They were divided into two groups: group A (26 patients) who underwent mitral valve replacement alone, and group B (24 patients) who underwent mitral valve replacement and tricuspid valve repair using De Vega annuloplasty technique. Results The result showed that the tricuspid regurgitation improved postoperatively, irrespective of whether the repair was performed or not. However, statistical differences between group A and group B were significant. Conclusion Concomitant tricuspid valve repair with mitral valve surgery offered better early postoperative tricuspid valve function in patients with moderate tricuspid regurge, who underwent mitral valve surgery for chronic mitral valve disease.
  - 932 100
Clinical and radiological assessment of transanal endorectal pull-through in children with Hirschsprung's disease
Magdy Ahmed Loulah, Ahmed Sabry EL-Gammal, Ahmed Mohamed Nabil
January-March 2015, 28(1):38-42
Objective The aim of this study was to evaluate the late outcome of transanal endorectal pull-through technique (TEPT) clinically and radiologically in patients with Hirschsprung's disease (HD). Background HD is a relatively common neonatal developmental disorder of the enteric nervous system. It leads to absent peristalsis in the affected bowel, which results in functional intestinal obstruction. Many surgical operations have been used to treat it; here we discuss TEPT, especially the late results of it. Patients and methods A retrospective study was conducted on 40 patients in whom TEPT was performed from 2010 and who were followed up for 2 years. Results The outcome of TEPT is satisfactory for both surgeons and patients, especially with respect to bowel habits; however, as it is a new surgical technique, we are awaiting further study results to support its more widespread use in the treatment of HD. Conclusion The clinical outcome is satisfactory. Postoperatively, a gradual recovery could be noted in the stooling patterns over time. The younger the patient operated on, the faster the recovery of stooling function.
  - 2,761 152
Bilateral central lymph node dissection with thyroidectomy for papillary thyroid cancer
Ahmad F El-Kased, Hossam A El-Foll, Ahmad S El-Gammal, Tarek H.A. Abu El-Nasr
January-March 2015, 28(1):43-48
Objectives The aims of the study were to evaluate the frequency and pattern of central neck lymph node metastasis in papillary thyroid cancer and its relation to the lateral neck lymph node metastasis. Also, this study aimed to evaluate the complications of central neck dissection. Background The indications and extent of central lymph node dissection (CLND) in the treatment of papillary thyroid carcinoma remain controversial, and its therapeutic effect remains debatable. Patients and methods A total of 30 patients diagnosed with papillary thyroid cancer were treated from 2011 to 2013. All patients underwent total thyroidectomy and bilateral central neck dissection. In patients with positive central lymph node metastases in frozen section, we performed ipsilateral lateral lymph node dissection removing levels II to V. Central lymph node metastases were analyzed. In addition, we investigated postoperative complications after total thyroidectomy and CLND. Results Among 30 patients, 12 (40%) had central lymph node metastases, with the ipsilateral paratracheal lymph nodes most commonly affected (40%). Of the 12 patients with positive central lymph node metastases, only two had positive lateral lymph node metastases. The frequency of temporary hypocalcemia, permanent hypocalcemia, and temporary vocal cord paralysis was 16.7, 6.7, and 6.7%, respectively. Conclusion CLND prevents nodal recurrence in the central compartment, which carries a high incidence of morbidity during surgery for recurrence. In addition, CLND, in good hands, does not contribute to the morbidity of total thyroidectomy (hypoparathyroidism and recurrent laryngeal nerve injury). We propose that total thyroidectomy and bilateral CLND are the least-recommended surgical treatments. Also, in clinically negative lateral nodes, we conclude that lateral lymph node dissection is not important even if central lymph nodes were positive for metastases.
  - 875 89
Oncoplastic breast-conserving surgery
Mahmoud A Elkhateb, Ayman A Shmilla, Soliman A El-Shakhs, Ahmed M Al-Barah, Abdelmoniem F Mohamed, Moharram A Mohammed
January-March 2015, 28(1):49-53
Objective To assess different techniques of oncoplastic breast-conserving surgery, according to breast shape, protrusion, size, and symmetry. Background Oncoplastic surgery has emerged as a new approach to allow wide excision for breast-conserving surgery without compromising the natural shape of the breast. It is based on integration of plastic surgery techniques for immediate breast reshaping after wide excision for breast cancer. Patients and methods This prospective study was carried out on 35 patients; all patients had breast tumor and were being managed at Menoufia University Hospitals by different modalities of oncoplastic breast surgery during the period from April 2012 to December 2013. The appropriate oncoplastic technique was selected for every patient taking into consideration the location and size of the mass and breast size and ptosis. Results Seven patients underwent simple oncoplastic procedures with volume displacement techniques, 20 patients underwent more advanced oncoplastic techniques of volume replacement with local dermoglandular flaps, and eight patients required reconstruction with distant pedicle musculocutaneous flaps. All our patients had negative clear specimen margins. Only three complications were encountered: one case of skin necrosis in the skin envelope after skin-sparing mastectomy and two cases of traumatic fat necrosis with the inverted-T technique. Conclusion This study showed that creative use of reconstructive techniques can yield excellent results, fulfilling all patient and surgeon expectations with a minimum rate of morbidity. Younger women with a small-size breast will benefit from a simple oncoplastic technique with volume displacement procedures. Women with large ptotic breasts need more complex mammoplastic techniques with or without flaps. Oncoplastic surgery should be the standard approach to breast cancer treatment whenever feasible.
  - 1,029 143
Evaluation of intraperitoneal and preincisional port site local anesthetic use in laparoscopic cholecystectomy
Hatem Mahmoud Sultan, Nehad Abdo Zaid, Ahmed Essam AlKafrawy
January-March 2015, 28(1):5-10
Objective The aim of the study was to evaluate the role of intraperitoneal and port site use of local anesthetic in laparoscopic cholecystectomy in postoperative pain relief. Background Laparoscopic strategies for managing intra-abdominal pathologies offer significant benefits compared with conventional approaches. Of interest are reports of decreased postoperative pain, resulting in shorter hospitalization and earlier return to normal activity. However, many patients still require strong analgesia postoperatively. This study analyzed the intraperitoneal and port site use of local anesthetic and its ability to reduce postoperative pain. Patients and methods For this study, 60 patients undergoing laparoscopic cholecystectomy were recruited and divided randomly into three groups: control (n = 20), intraperitoneal local anesthetic irrigation of bladder bed (n = 20), intraperitoneal and port site local anesthetic (n = 20). All patients had standard preoperative, intraoperative, and postoperative care. Pain scores were recorded by the physician after 1, 2, 4, 6, 8, 10, and 12 h postoperatively using a standard 0-10 pain scoring scale. In addition, peristalsis auscultation, passing flatus, and movement from bed were recorded. Results Intraperitoneal and port site local anesthetic use significantly reduced postoperative pain in comparison with all other treatments (P < 0.05). Conclusion Intraperitoneal and port site local anesthetic is an effective method for controlling postoperative pain. It significantly helped to reduce opiate use and contributed to rapid mobilization, leading to short hospitalization and possible reduction in treatment cost.
  - 1,415 192
Comparative study between the conventional laparoscopic cholecystectomy and clipless cholecystectomy using a harmonic scalpel
Said Ibrahim El Mallah, Hatem Soltan, Nehad Abdo Zaid, Moharam Abd Elsamie, Reda Mohamed Eltiras
January-March 2015, 28(1):54-61
Objective This was a comparative study between laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel. Background This study aimed to compare the laparoscopic conventional cholecystectomy and clipless cholecystectomy using a harmonic scalpel in terms of the duration of the operation, intraoperative blood loss, postoperative complications, postoperative pain, and hospital stay. Patients and methods This study included 80 patients who were classified into two groups: group A (40 patients) was subjected to laparoscopic cholecystectomy by clipping of the cystic duct and cystic artery and dissection of the gall bladder from the gall bladder fossa by electrocautery and group B (40 patients) was subjected to laparoscopic cholecystectomy by a harmonic scalpel, closure and division of both the cystic duct and artery and dissection of the gall bladder from the liver bed by a harmonic scalpel. The intraoperative and postoperative parameters were determined including duration of operation, intraoperative blood loss, postoperative drainage, postoperative pain, complications, and hospital stay. Results The harmonic scalpel provided a shorter operative duration than the conventional method (34.21 ± 9.6 vs. 41.7 ± 13.79, respectively, P = 0.006), and the difference was statistically significant. A statistically significantly lower volume of intraoperative blood loss was observed in group B than group A (64.20 ± 44.01 vs. 96.62 ± 53.33, respectively, P = 0.004) and fewer incidences of gall bladder perforation in group B (7.5 vs. 17%, respectively, P = 0.176), but this was not statistically insignificance, and a lower rate of conversion to open cholecystectomy in group B than group A (0 vs. 5%, respectively, P = 0.246), but this was not statistically significant. The amount of postoperative drainage was significantly less in group B than group A (60.30 ± 11.48 vs. 79.0 ± 36.95, respectively, P = 0.004). Three patients in group B with dilated cystic duct discovered intraoperative and clip technique used for closure; otherwise, no postoperative bile leak was encountered in group B, but it occurred in 5% of patients in group A as a minor biliary leak. In terms of postoperative pain, it was less in group B than group A at 12 and 24 h (45 vs. 70%, P = 0.024, and 37.5 vs. 60%, P = 0.044, respectively), which was statistically significant and insignificant at 48 h and 1 week. Visual analogue scale in group B was lower than that in group A at 12 and 24 h (3.12 ± 0.33 vs. 3.49 ± 0.49, P = 0.01, and 2.5 ± 0.34 vs. 3.34 ± 0.47, P = 0.01, respectively) and statistically significant and insignificant at 48 h and 1 week; the hospital stay was shorter in group B than in group A (20.15 ± 5.65 vs. 24.65 ± 6.22, P = 0.006) and the difference was statistically significant. Conclusion The harmonic scalpel can be used safely for sealing of the cystic artery and cystic duct less than 6 mm in size in laparoscopic cholecystectomy without a risk of major injuries or leak; if the diameter is more than 6 mm, the clips technique should be used. It is better than electrocautery in terms of not just a faster and safer surgery, but also less intraoperative blood loss and less postoperative drainage, with decreased associated morbidity and pain and early return home; however, it is very costly.
  - 1,155 142
The outcome of bilateral subfrontal approach of large olfactory groove meningioma
Yasser Bahgat El-Sisi, Magdy El Sayed Rashed, Adel Mahmoud Hanafy, Essam El-Din Gaber Saleh, Hossam Abd Al Hakin El Noomany, Ahmed Fathy Sheha
January-March 2015, 28(1):93-98
Objective The aim of the study was to evaluate the value of bilateral subfrontal approach for management of olfactory groove meningioma focused on preoperative and postoperative investigations for ophthalmologic disturbance. Background Olfactory groove meningiomas arise in the midline along the dura of the cribriform plate and may reach a large size before producing symptoms. There are many surgical approaches such as bilateral subfrontal, unilateral subfrontal, and pterional approaches for this lesion. Patients and methods Over a 3-year period, 20 patients with olfactory groove meningiomas more than 4.5 cm in diameter were operated upon using the bilateral subfrontal approach. Data related to clinical history, symptoms, signs, and outcome were obtained by review of the patient's clinical notes, operative reports, histopathological records, follow-up records, and radiological images. Operative and postoperative events were noted with a follow-up period of 6 months. Results Twenty patients with olfactory groove meningiomas were approached by bilateral subfrontal approach. The most common presenting symptom was headache, which was seen in 16 patients (80%). On admission, five patients (25%) had mental status changes, nine patients (45%) presented with associated visual complaints, and two patients (20%) had epilepsy at presentation. Within the first month after surgery, the postoperative visual acuity was improved in two patients, whereas in seven patients it remained unchanged. In two patients, visual field defects improved and in one patient the defects resolved completely. Conclusion Visual deficits can be improved in patients with olfactory groove meningiomas after a bifrontal approach, after 6 months follow-up period without additional neurological deficits.
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Patterns and management of congenital nasal clefts
Fouad Mohamed Ghareeb, Awatef Al-Sayed Farghaly, Ahmed Mohammed Al Barah, Yasser Mohammed El Sheikh, Hossam Hassan Abd Al Raheim Fawzy
January-March 2015, 28(1):99-106
Objective The aim of the study was to study different patterns of congenital nasal clefts and different methods of their management trying to put forward a road map for their treatment. Background Because of the rarity of atypical facial clefts, little is written with respect to patterns and plans of management. This study will spot light on atypical facial clefts affecting the nose (atypical nasal clefts) with respect to different patterns and plans of management. Patients and methods This was a retrospective and short prospective study that was conducted in the Department of Plastic Surgery, Menoufia University, from 2001 to 2014. The study included 26 patients with atypical nasal clefts. Those patients were classified according to Tessier classification into Tessier type 0, 1, 2, and 3. All patients were evaluated for the type of facial clefts, pattern of nasal involvement, and associated congenital anomalies. In all, 20 of them underwent surgical repair in one or more stages according to complexity of the deformity. The study describes different plans of reconstruction used for management. Results The statistical analysis of data was descriptive and focused on description of different patterns of Tessier type. It showed that the highest incidence was Tessier 0, which included 17 cases found in eight patterns, followed by five cases in Tessier 1 in three patterns, two cases in Tessier type 2 in two different patterns, and two cases in Tessier type 3 in two patterns. The analysis of data showed that the most common associated congenital anomalies were cleft lip and hypertelorism. With respect to management, analysis of data showed the variation in number of operations, timing of first operation, and type of surgical intervention according to complexity and pattern of deformity. Conclusion Atypical nasal clefts can be found in a very wide range of patterns, ranging from simple esthetic deformity to complete agenesis or bifidity of the nose. Management of these cases requires good analysis of the pattern of nasal cleft and we provided a treatment algorithm for each pattern.
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Evaluation of modified Alvarado score in the diagnosis of suspected acute appendicitis
Samir M Kohla, Moharram Abdel-Samie Mohamed, Fawzy Abu-Bakr Bakr, Hesham M Emam
January-March 2015, 28(1):17-20
Objective The aim of the study was to evaluate the efficacy of modified Alvarado score in the diagnosis of acute appendicitis. Background Diagnosis of acute appendicitis is sometimes difficult. Prompt and accurate diagnosis of appendicitis is crucial in lowering the incidence of complications caused by appendiceal rupture. A number of scoring systems have been advocated to minimize the number of negative appendectomies; the most prominent and most commonly used of those scores is that developed by Alvarado and modified by Kalan. Patients and methods A total of 100 patients with acute lower abdominal pain suspecting acute appendicitis were included, examined clinically, and their modified Alvarado score was calculated and listed. All specimens of appendectomies were sent to histopathological examination and then their results were compared with the results of modified Alvarado score. Results The results of this study showed that modified Alvarado score at the cutoff value of at least 7 has a sensitivity of 93.33%, specificity of 52.94%, accuracy of 84.42%, and negative appendectomy rate of 12.5%. Conclusion The Alvarado score is a cheap, reliable, and reproducible diagnostic tool. When the score is high (≥7), there are strong indications for urgent surgery. When the score is low (<4), the diagnosis of appendicitis is very unlikely.
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Bimanual microincision versus coaxial phacoemulsification cataract surgery
Saber H El-Sayed, Amin F Ellakwa, Nermeen M Badawi, Abeer M Wahba
January-March 2015, 28(1):162-167
Background Bimanual microincision and coaxial phacoemulsification are the modalities of cataract surgery. Objectives The aim of the study was to evaluate bimanual microincision phacoemulsification versus coaxial phacoemulsification cataract surgery. Patients and methods Thirty patients were enrolled between December 2011 and March 2013, all with symptoms related to cataract. Fifteen patients were randomly assigned to the bimanual microincision group and another 15 patients to the coaxial phacoemulsification group. All patients were followed after 1 day, 1 week, 1 month, and 3 months of the procedure. The primary outcome of our study was lowering of astigmatism in the bimanual microincision procedure. Results The bimanual group demonstrated a reduced surgically induced astigmatism (SIA). The coaxial group demonstrated a slight rise in SIA. There is a highly significant difference between postoperative SIA in both groups during the postoperative period (P < 0.001). Conclusion Microincisional cataract surgery using bimanual phacoemulsification has many advantages but it is limited by the lack of suitable intraocular lenses for implantation through microincisions; hence, switching to this technique from the conventional one still depends on the surgeon's performance.
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Risk evaluation for cerebrovascular accident in cases of retinal vein occlusion
Faried M Wagdy, Ahmed A El-Adly, Osama A El-Morsy, Hassan G Farahat
January-March 2015, 28(1):181-183
Objectives The aim of this study was to evaluate the risk factors that may predict the development of cerebrovascular accidents (CVAs) in patients with retinal vein occlusion (RVO). Background Risk factors for RVO include hypertension, hyperlipidaemia, diabetes mellitus and vascular diseases, which are the same risk factors for CVAs. Materials and Methods Twenty patients with RVO (group A) and 20 normal controls with no history of RVO (group B) were examined and investigated using colour fundus photography and fluorescein angiography, carotid duplex ultrasonography and blood examinations for bleeding disorders, diabetes mellitus and hyperlipidaemia. The risk for CVAs was evaluated in both groups during a follow-up period of 12 months. Results Four patients (20%) in group A suffered from some degree of CVA throughout the follow-up period, ranging from transient ischaemic attacks in three patients to cerebrovascular stroke in one patient. In contrast, none of the other control group individuals suffered any type of CVA during the follow-up period. Sixteen patients (80%) in the cases group had some degree of stenosis of their ipsilateral internal carotid artery (ICA), compared with only 12 individuals (60%) in the control group. The mean percentage degree of stenosis of the ipsilateral ICA detected by carotid ultrasonography in group A was 15.25%, whereas the mean percentage degree of stenosis in group B was 8%. Conclusion The number of individuals who had CVAs and some degree of stenosis of their ipsilateral ICA was higher in patients with RVO than in the control group, and the mean percentage degree of carotid stenosis was higher in group A than in group B.
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Macular thickness analysis following complicated versus uncomplicated cataract surgery using optical coherence tomography
Abdelrahman El-Sebaey Sarhan, Osama Abdallah El Morsy, Mohamed Gaber Abdallah Abdallah
January-March 2015, 28(1):184-190
Objective Evaluating the influence of risk factor of intraoperative complications such as rupture posterior capsule with vitrous loss on the postoperativemacular thickness using optical coherence tomography (OCT). Background Cystoid macular edema (CME) remains an important cause limiting favorable visual outcomes following cataract surgery. Thecomplicated cataract surgery (with posterior capsular tear) could be a strong risk factor for development of macular edema than the uneventful surgeries. Methods 70 cases, 62 patients underwent phacoemulsification surgeries divided into 5 groups anda healthy control group Group I: Uncomplicated cataract surgery (non-diabetic) Group II: Uncomplicated cataract surgery (Diabetic patient) Group III: Complicated cases with PCR and Ant vitrectomy (non-diabetic) Group IV: Complicated cases with PCR antvitrectomy (Diabetic patient) Group V: Complicated cases with PCR ant vetrectomy, AC IOL Group VI: Normal cases without cataract extraction Patients follow up by Visual acuity, fundus ,IOP and Maculathickness map using OCT scan (RS-3000RetinaScan, NIDEK Co., Japan) was conducted after 1 month. Results We found that, macular thickness was significantly higher after cataract surgeries with posterior capsular tear than the unevetiful surgeries, Also diabetes did not influence significantly the thickening of the macular regions after uncomplicated cataract surgery. Conclusion After cataractsurgery, there is non significant increase of foveal thicknessThe complicated cataract surgeries with rupture posterior capsule and vitrous loss may be a risk factor, while diabetes may not be a risk factor for development of post operative macular oedma.
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Phacoemulsification versus manual small incision cataract surgery for treatment of cataract
Saber H El-Sayed, Hoda MK El-Sobky, Nermeen M Badawy, Eslam AA El-Shafy
January-March 2015, 28(1):191-196
Objectives The aim of the study was to evaluate the effect of sutureless scleral tunnel manual small incision cataract surgery (MSICS) on the postoperative astigmatism in comparison with the effect of phacoemulsification. Background Nonphaco sutureless cataract extraction retains most of the advantages of phacoemulsification with comparable visual outcome and is affordable. Materials and methods Phacoemulsification and MSICS were performed in 20 eyes of 20 patients. Both techniques were performed at the Department of Ophthalmology, Menoufia University Hospital, Menoufia Governorate, Egypt. The study was conducted between 1 September 2011 and 28 February 2013. The outcome was evaluated in both techniques in terms of early visual rehabilitation, surgically induced astigmatism, and final best-corrected visual acuity. Results Of the 20 patients who underwent phacoemulsification, 60% were male patients and 40% were female patients. Of the 20 patients who underwent MSICS, 45% were male patients and 55% were female patients. Both surgical techniques achieved excellent visual outcomes with low complication rates. The initial visual recovery on the first postoperative day was better in the patients who underwent phacoemulsification, with the uncorrected visual acuity better than or equal to 6/18 in 75% of the patients, whereas the percentage was 60% in the MSICS group. The initial difference was nearly equalized within 4 weeks. At the sixth month, 85% of the patients in the MSICS group had uncorrected visual acuity better than or equal to 6/18 versus 90% of the patients in the phacoemulsification group. The surgically induced astigmatism at the sixth month was comparable in both techniques, 1.18 ΁ 0.2 D in the phacoemulsification group versus 1.2 ΁ 0.23 D in the MSICS group. Conclusion Both phacoemulsification and MSICS achieved excellent visual outcomes with low complication rates. MSICS is less technology dependent; hence, it is less expensive and more appropriate for treatment of advanced cataracts prevalent in the developing world.
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Management of pre-existing regular astigmatism in phacoemulsification
Mostafa Kamal Nassar, Khaled El-Gonemy Said-Ahmed, Osamaa Abd-Allah Al-Morsy, Dina Said Gawish
January-March 2015, 28(1):197-202
Objectives The objective of this study was to compare the effect of single clear corneal incision (CCI) on the steep axis with opposite clear corneal incisions (OCCIs) on pre-existing regular corneal astigmatism in cataract patients having phacoemulsification. Background Correction of pre-existing regular astigmatism in phacoemulsification. Patients and methods This randomized prospective clinical study included 30 eyes of 30 cataract patients with corneal regular astigmatism greater than 1 D. The patients were randomly divided into two groups, each group involving 15 eyes. Paired 3 mm CCI were made on the steep axis in Group A and single in Group B. Preoperative evaluation included uncorrected visual acuity, refraction, best-corrected visual acuity, applanation tonometry, fundus examination, biometry, keratometry, and corneal topography. The vertical axis was marked before peribulbar anesthesia was given and routine phacoemulsification was performed through a 3-mm CCI on the steep axis. An additional opposite 3-mm self-sealing CCI was made opposite to the first one in Group A. Patients were examined 2, 4, and 8 weeks postoperatively. Visual acuity, refraction, keratometry, and corneal topography were used to evaluate the improvement. Results The mean preoperative and postoperative topographic corneal astigmatism was 1.95 D ± 0.83 (SD), 0.59 D ± 0.47 (SD) and 1.93 D ± 0.51 (SD), 1.53 D ± 0.62 (SD), respectively, in Groups A and B. There was a significant difference between the mean values of astigmatism in the two groups postoperatively. The mean surgically induced astigmatism, measured by a vector-corrected method, was 1.2 ± 80.11 D and 1.09 ± 0.13 D in Group A and Group B, respectively (P = 0.00). The mean values of best-corrected visual acuity were 0.11 ± 0.13 in Group A and 0.22 ± 0.15 in Group B postoperatively (P < 0.05). Conclusion OCCIs on the steep axis were more effective than single CCI in the correction of mild to moderate pre-existing corneal astigmatism.
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The effect of prophylactic laser barrage treatment before phacoemulsification in high myopia
Moustafa Kamal Nassar, Hatem Mohammed Marey, Kareem Mohamed Abdelreheem
January-March 2015, 28(1):203-206
Objective The aim of this work was to study the effect of prophylactic laser barrage treatment before phacoemulsification in high myopia. Background High myopia is considered as an important risk factor for the development of peripheral retinal degeneration and the subsequent development of retinal detachment, and hence, prophylactic laser barrage treatment is used for such uses. Patients and methods Thirty eyes of 20 patients with high myopia were divided into the following two groups: group I, high myopia with peripheral retinal degeneration subjected to laser retinopexy, and group II, high myopia with peripheral retinal degeneration not subjected to laser retinopexy. The two groups after undergoing phacoemulsification had been followed for the development of retinal detachment. Results Prophylactic laser barrage treatment significantly reduces the incidence of retinal detachment after phacoemulsification in high myopia. Conclusion Prophylactic laser barrage treatment decreases the incidence of retinal detachment after phacoemulsification in high myopia.
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Incidence of amblyopia in the Menoufia University outpatient clinic
Hoda Mohamed Kamel El-Sobky, Khaled El-Ghonemy Said Ahmed, Moataz Fayez El-Sawy, Sherif Mohammed Ibrahim Sakr
January-March 2015, 28(1):207-213
Objectives The aim of the study was to estimate the incidence of amblyopia in children aged between 5 and 15 years and ascertain the most common causes of amblyopia in this age group in the Menoufia University outpatient clinic. Background Amblyopia is one of the leading causes of acquired preventable monocular visual impairment. Methods This is a cross-sectional clinical study that was carried out between March 2012 and September 2012 in children between the ages of 5 and 15 years (mean age 8.013 ΁ 3.381 years) attending the Menoufia University outpatient clinic. After obtaining patient consent all patients underwent refraction, vision, and subjective refraction tests. Amblyopia was defined as best-corrected visual acuity with a two-line interocular optotype acuity difference with no pathology. Results The study was conducted on 510 patients; 38 of them (6.3% of male patients and 8.6% of female patients) had amblyopia, with an estimated incidence of 7.45%. Amblyopia decreased significantly with age (P = 0.002). Of the 38 amblyopic patients, 26 (68.42%) had anisometropic amblyopia and 12 (31.58%) had strabismic amblyopia. The most common type of amblyopia was anisometropia, followed by strabismic amblyopia. Hypermetropia was the most common refractive error in anisometropic amblyopia. Conclusion The incidence of amblyopia in this study was 7.45%, which is high compared with other studies; however, the sample in this study was taken from diseased persons attending the outpatient clinic and not from a healthy population. Proper ophthalmological screening of preschool children should be carried out, including extraocular examination, fundus examination, and visual acuity testing, with special emphasis on detection of errors of refraction.
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Comparison between VY flap and rhomboid flap in the treatment of pilonidal sinus
Ashraf Abdulhady Zeineldin, Asem Fayed Moustafa, Ibrahim Ayman Ibrahim Saadeldin
January-March 2015, 28(1):21-26
Objective The present work was designed to compare a VY flap and a rhombiod flap in the treatment of pilonidal sinus. Background The pilonidal sinus is a tract that usually contains hair. It occurs under the skin between the buttocks (the natal cleft) a short distance above the anus. The sinus track traverses in a vertical direction between the buttocks. Rarely, a pilonidal sinus occurs in other sites of the body such as the axilla, groin, interdigital webs, or the feet. The exact cause is not clear. There are various theories. For example, one theory states that the problem may develop from a minor congenital or hereditary abnormality in the skin of the natal cleft, in which the hair grows into the skin rather than outwards. Materials and methods We studied 30 patients aged 19-47 years (average, 30 ± 10 years) presenting to the outpatient clinic of El-Menoufia university hospital and El-Helal insurance hospital at Shebin El-Kom with pilonidal sinus from December 2012 and May 2013. The patients were followed up until July 2013. A total of 15 patients (50%) were treated with a VY flap and 15 (50%) were treated with a dufourmentel flap. Results The outcome was successful in 14 of 15 patients who received a VY flap and 15 of 15 patients who received a dufourmentel flap. The operative time is shorter in the VY method than the dufourmentel method (P < 0.05). Hospital stay was shorter in the dufourmentel group than the VY group. The duration of follow-up was 6 months in both groups. Recurrence developed in only one patient from the VY group. Excellent results were more commonly observed in younger patients. Conclusion Recovery following treatment with a dufourmentel flap is better than with the other method.
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Validity of P1 testing as an objective tool for hearing aid verification in children
Mohammed Kammar El-Sharnouby, Madiha Mohammed El-Mousely, Ahmed Abd El-Moniem Ragab, Ahmed Mahmoud Zein El-Abedein
January-March 2015, 28(1):213-218
Objective The aim of this study was to determine the efficiency of P1 as an objective tool for verification of hearing aids in children. Background Hearing loss in childhood interferes with the normal development of speech. The use of hearing aids improves speech perception. Cortical auditory-evoked potentials (CAEPs) (dominated by a large P1 response) may be a good tool for assessment of hearing aids. Patients and methods In this study, 200 children ranging in age from 3 to 6 years were divided into two groups: the control group (50 volunteers), which included children with normal hearing sensitivity, matched for age and sex with the study group, and the study group, which included 150 children with sensorineural hearing loss. This group was subdivided as follows: subgroup a (group with well-fitted hearing aids), subgroup b (poorly fitted group), and subgroup c (not wearing hearing aids). All were subjected to a full assessment of history, psychosocial evaluation, otological examination, basic audiological evaluation, and the CAEPs test, which was performed serially each month for subgroup a for 15 months. Results The P1 wave dominates the CAEPs as it appeared in 100% of the normal children. The N1 wave, in contrast, did not appear in all individuals. In the study subgroup a, P1 appeared with longer latency, which led to a decrease in hearing aid usage to normal after 15 months. Children of subgroup b showed less improvement in P1 latency. In subgroup c, only very few children gave for P1 with delayed latency. Conclusion P1 is reliable for the evaluation of hearing aids. It appears in all children and usually improves to normal values after 15 months of using suitable hearing aids. The N1 wave, in contrast, is not a reliable wave.
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Endoscopic endonasal surgery in orbital decompression and orbital reconstruction
Omar Abd El-Moneem El-Banhawy, Abdel-Khalek Ibrahim El-Saadany, Ayman Aly Abd El-Fattah, Heba Abd El-Rehem Abd-Allah, Hosam Adel Hussein Omar
January-March 2015, 28(1):219-224
Objectiv The aim of this study was to clarify and evaluate the role and the outcome of endoscopic endonasal surgery in both orbital decompression and orbital reconstruction. Background Traditional external techniques are now known to reduce proptosis significantly, but have the disadvantage of cosmetic morbidity in terms of a cutaneous scar and a high incidence of postoperative complications. Recent advances in endoscopic sinus surgery have extended its applications beyond the nose to the orbit. Orbital decompression, drainage of subperiosteal abscess, optic nerve decompression, and orbital wall reconstruction are performed very safely and effectively by endoscopic intranasal surgery. Patients and methods Fifty-four patients indicated for endoscopic orbital decompression or reconstruction were divided according to the cause into five groups (20 infection, eight inflammatory, eight neoplastic, eight congenital, and 10 traumatic). Preoperative evaluations performed were history taking, physical examination, and computed tomography and MRI of orbit and paranasal sinuses. After creating an endoscopic wide middle meatal antrostomy dealing with the pathology causing extraconal orbital compression and in intraconal compression penetrate the lamina papyracea and periosteum until prolapsed fat fill the ethmoid sinus. Reconstruction was performed by removal of the fractured bone, extraocular muscle reposition with support using Foley's catheter in floor fracture and a silastic sheet with Merocel packing in medial wall fracture. Results There was significant proptosis reduction in all groups, especially in the infection group (P < 0.001), with a mean proptosis reduction of 4 mm in the same group. Vision was significantly improved in all groups. Limited ocular motility improved significantly in traumatic and infection groups (P < 0.05). Complications were limited, and diplopia (16.7%) was the most frequent complication. Conclusion Endoscopic nasal decompression of the orbit is a safe and effective approach for reducing proptosis and improving vision and ocular motility in cases of orbital compression, which include infection, inflammatory, neoplastic, congenital, and traumatic causes. Endoscopic intranasal reduction of the orbital floor with a Foley's catheter balloon and with a silastic sheet and Merocel packing of the medial orbital wall provided good functional results and definite advantages. Complications were limited.
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Safety and efficacy of bipolar TURP in management of benign prostatic hyperplasia
Mohamed Nabil El-Helbawy, Mohamed Marzok Abd-allah, Tarek Mohamed Abd-Elbaky, Fatma Ahmed Elserafy
January-March 2015, 28(1):225-232
Objectives The aim of this study was to evaluate the safety and clinical efficacy of bipolar transurethral resection of the prostate (TURP) in the treatment of symptomatic benign prostatic hyperplasia as compared with standard monopolar TURP. Background Monopolar TURP, which was considered the gold standard surgical therapy for men with lower urinary tract symptoms due to benign prostatic hyperplasia, was recently challenged by bipolar TURP, which uses bipolar energy for transurethral prostate resection in saline media, thus avoiding the need for glycine irrigation and its associated complications. Materials and methods From October 2011 to October 2013, 70 consecutive patients with symptomatic benign prostate hyperplasia were randomized into a prospective study comparing the two modalities. Resection time, resected volume, resection speed, and ratio were analyzed in both groups. Blood loss and volume of decline of hemoglobin and sodium values were determined. Postoperative catheter time and hospital stay were also recorded. Intraoperative and postoperative complications and the need for blood transfusion were noted. The improvements in International prostate symptoms score, Qmax , and postvoid residual urine after 1 and 3 months were also recorded for all patients. Results Comparative data on International prostate symptoms score, maximum flow rate (Qmax ), and postvoid residual urine volume showed a significant improvement with respect to baseline values in both groups, but the differences between the two groups were insignificant except for Qmax at 3 months' follow-up. Resection speed and ratio, intraoperative blood loss, serum sodium loss, postoperative catheterization time, hospital stay, and complication rate were significantly better in the bipolar group. Conclusion Bipolar TURP is safer than monopolar TURP because of lower risk for TUR syndrome, less intraoperative bleeding, and lower incidence of postoperative complications.
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Serum insulin and C-peptide levels as markers of pre-eclampsia in pregnant women
Mohammed A El Sayed, Alaa M Abdel Gayed, Abeer H El Shalakany, Youmna M Murad
January-March 2015, 28(1):233-238
Objectives This study aimed to detect the relation between fasting C-peptide level and serum insulin level in pre-eclamptic pregnant women. Background Pre-eclampsia is a systemic disease that is characterized by increased vascular resistance, endothelial dysfunction, proteinuria, coagulopathy, and hypertension. Similarities in certain biochemical variables between pre-eclampsia and the insulin resistance syndrome imply a possible link between insulin resistance and pre-eclampsia. Patients and methods A total of 60 pregnant women were included in this study after the approval of the ethical committee of the Alexandria University (where the study was conducted in); then, they were divided into two groups: 30 normal pregnant women as controls and another 30 pregnant women with the complication of pre-eclampsia served the study group. This group was subdivided into 10 patients with severe pre-eclampsia and another 20 with mild pre-eclampsia. All the patients were subjected to the oral glucose tolerance test (OGTT), assessment of fasting serum insulin and fasting C-peptide, and urine for dipstick. Results A statistically significant difference was found between the two groups in the mean arterial blood pressure, systolic blood pressure, and diastolic blood pressure. There was a statistically significant difference between the two groups in BMI as increased BMI was associated with pre-eclampsia. There were statistically significant differences between the two groups in serum C-peptide, serum insulin, and protein in urine. Conclusion Serum C-peptide and serum insulin levels were significantly lower in women with severe pre-eclampsia than in women with mild pre-eclampsia and normotensive pregnant women, with weak associations to pre-eclampsia. BMI was significantly higher in women with severe and mild pre-eclampsia than in normotensive pregnant women, with strong associations to pre-eclampsia.
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Comparison of oral misoprostol and oxytocin for labor induction in prelabor rupture of membranes at term
Ayman A Shabana, Osama A El Kilani, Nabih I El Khouly, Shereen M Tayel
January-March 2015, 28(1):239-244
Objective This study aims to compare the efficacy and safety of oral misoprostol with oxytocin infusion for induction of labor in women with prelabor rupture of membranes (PROM) at term. Background PROM at term is one of the most common complications of pregnancy. It is an important cause of perinatal morbidity and mortality, particularly if it is associated with a prolonged latency period from membranes rupture to delivery. Patients and methods This prospective randomized study included 100 pregnant women admitted to the Department of Obstetrics and Gynecology at El-Mahalla General Hospital presenting with PROM at term. The women were assigned randomly to one of the two equal groups (groups A or B): group A, which received 100 mg oral misoprostol every 4 h for a maximum of three doses, and group B, which received an intravenous infusion of oxytocin starting with a dose of 4 mU/min with an incremental increase of 4 mU/min every 30 min until a maximum dose of 32 mU/min. The primary outcome variable was time from induction to vaginal delivery. The secondary outcomes were mode of delivery, maternal, and neonatal outcomes. Results The study showed that the time intervals from induction to delivery were significantly shorter in the misoprostol group than in the oxytocin group (6.59 ± 1.91 and 9.30 ± 2.58 h, respectively; P < 0.001). Also, there were no significant differences in maternal and neonatal outcomes between both groups. Conclusion Oral misoprostol at a dose of 100 mg every 4 h was not only as successful as oxytocin for labor induction in women presenting with PROM at term but also reduced the duration of labor in nulliparous women. Oral misoprostol was safe in terms of maternal and neonatal outcomes.
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The value of nuchal translucency measurement as an early predictor of congenital fetal malformation
Mahy Nabil Mahmoud Egiz, Ahmed Nabil Abd El Hamid, Alaa Masoud Abd El Gayed, Ragab Mohamed Dawood
January-March 2015, 28(1):245-249
Objective The aim of the study was to estimate the value of the nuchal translucency (NT) measurement during the period from 10th to 14th week of gestation in predicting the possibility of congenital malformation in these fetuses. Background First-trimester screening is typically conducted between the 11th and 13th weeks 6 days of gestation. At this time, NT, free b-subunits of human chorionic gonadotropin (fB-hCG), and nasal bone are powerful markers for detection of fetal conditions. Methods The present study was carried out at the department of Obstetrics and Gynecology at Menoufyia University Hospital during the period between 2012 and 2014. A total of 120 women were included in the study. The studied patients were divided into two groups. Thorough history taking, full examination, routine laboratory investigations, hCG, and pregnancy-associated plasma protein A were taken. Ultrasound was performed to detect NT. The collected data were organized, tabulated, and statistically analyzed using SPSS software computer package. For quantitative data, mean, minimum, maximum, and SD were calculated and comparison between two means was performed; for qualitative data, number and percent distribution were calculated and comparison between two groups was performed. A normal value of NT is usually less than 2.5-3.0 mm in thickness; assessment of the biochemical markers and their correlation with malformed fetuses number was performed, and past history was taken from mother. Results The total number of women enrolled in the study was 120; four of 11 cases with congenital fetal malformation were with positive family history. NT in the affected fetuses with a mean 2.65 mm in the first group and 3.3 mm in the second group reflects a highly significant relationship. The cutoff point of NT is 2.55 mm with a sensitivity 73.6% and specificity 80.3%, whereas combined NT, B-hCG, and pregnancy-associated plasma protein A has 100% sensitivity and 35.8% specificity. Conclusion Prenatal screening has become now an integral part of obstetric care and raises the responsibility and awareness of neonatal care. Most women prefer to undergo screening first to find out whether the fetus's risk for birth defect is high.
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Surgical management of congenital scoliosis
Yasser Hasan El Miligy, Mahmoud Mohamed Hadhoud, Ahmed Ibrahim Zayda, Ashraf Abdel Aziz Abdel Raouf
January-March 2015, 28(1):133-141
Objective The aim of this study was to assess outcomes and complications in patients surgically treated for congenital scoliosis. Background Congenital scoliosis due to hemivertebra and unsegmented bar is most often progressive and requires surgical treatment. The recommended surgical options include 'in-situ' fusion, convex hemiepiphysiodesis, and hemivertebra excision. Patients and methods This study included 20 patients (six boys and 14 girls). The age at operation was between 4 and 18 years. Two techniques were used: the anterior procedure and the posterior procedure. The anterior procedure involves thoracotomy and the thoracoabdominal approach. In this procedure disc excision above and below the level of the anomaly was performed and the segment of the vertebral column (hemivertebra, segment of unsegmented bar) that would be excised was determined. In the posterior procedure, posterior correction, fixation, decortications, and grafting were performed. Fixation was carried out using claw, sublaminar wires, pedicular screws, and rods. Results 'In-situ' fusion does not address the anomaly directly; it allows a moderate correction rate but is associated with long spinal fusion. Hemivertebral resection directly addresses the spinal anomaly; it produces the best correction results and is a safe procedure to perform. The average angle after posterior correction and fusion of congenital scoliosis was 37.5΀ (range from 15 to 60΀). The percentage of correction was 55% (range from 20 to 90%). The early postoperative correction following the staged combined anterior and posterior correction, and fusion was 60%, ranging from 40 to 80΀. Conclusion The treatment of congenital scoliosis focuses on early diagnosis and appropriate surgical management before the development of large curves. All of the procedures described can be effective and safely performed if correctly selected and performed by an experienced team of surgeons.
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Role of retrograde short nail in the treatment of supracondylar femoral fractures (extra-articular type A)
Hisham Mohamed Zaki Elmowafy, Bahaa Zakarya Mohamed Hassan, Ahmed Mohamed Rushdy Nassar
January-March 2015, 28(1):142-148
Objectives The aim of the study was to evaluate the results of retrograde short nailing in the treatment of supracondylar femoral fractures (type A, extra-articular fracture). Background The incidence of distal femur fractures is increasing in our country as traffic accidents increase. Problems with distal femur fractures may not be limited to the femur itself, but may extend to internal knee structures. Patients and methods This work was a prospective study of 30 patients with supracondylar femoral fractures (extra-articular type A) treated with a short retrograde femoral nail. All patients were evaluated both clinically and radiologically through routine follow-up visits and all information concerning each patient was collected and recorded using the patient information sheet and data were tabulated and evaluated. Results In our study of 30 patients with type A supracondylar fractures treated with a retrograde nail, we found excellent results in eight patients, good results in 16 patients, fair results in four patients, and poor results in two patients (P > 0.040). Conclusion Treatment of supracondylar femoral fractures (type A, extra-articular fracture) with a retrograde short nail yields satisfactory results in adults.
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Evaluation of the results of management of acute extensor tendon injuries of the hand
Mohammed Ahmed Kadah
January-March 2015, 28(1):149-153
Objectives The aim of this study was to prospectively assess the results after primary extensor tendon repair and to analyze the factors affecting the results, such as the zone of injury, multiplicity of digits and zones affected, splint type, social class of patients, and the associated bone injury. Background Acute extensor tendon injuries of the hand is a common lesion due to the superficial nature of the extensor tendons and its adjacency to bone, which makes it more liable to injury than flexor tendons. Materials and methods During a period of 14 months, 30 hands with acute extensor tendon injuries in 29 patients (as one patient had bilateral hand affection) were studied prospectively regarding cause of injury and affected zone (s) and finger (s). Two of them were lost in follow-up postoperatively. The final results were based on 28 hands in 27 patients, where primary extensor tendon repair was carried out. The patients were followed up for an average duration of 8.5 months ranging 3-14 months and were evaluated according to Miller's scoring system. Results The final results of 46 digits with acute extensor tendon injury were reported. The excellent and good results represented 74.9% of the all final results. The best results were obtained in thumb and in zone TV and the worst results were seen in the ring finger and zone III. Multidigits and multifingers was associated with the worst results. Conclusion Multidigits and multiinjury zones involved have a poor effect on final results of extensor tendon injury. The results of zones III gave the worst results compared with other zones. More poor results were found in extensor tendons associated with bone injury. Postoperative splinting after extensor tendon repair is still under debate. From the economic point of view, a static regimen may be preferred, as it is much cheaper besides it requires little supervision by the physician.
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Study of inguinal versus retroperitoneal approach in the treatment of varicocele
Ayman Ahmed Omar, Hesham Shafik Abou Greda, Mohamed Samir Aboulfotoh
January-March 2015, 28(1):1-4
Objective The aim of the study was to assess the efficacy of the inguinal approach versus the retroperitoneal approach in the treatment of varicocele. Background Published results have shown that the inguinal approach has several advantages over the retroperitoneal approach in terms of lower incidence of recurrence, easier applicability, and greater safety. Patients and methods This prospective study was conducted from April 2013 to February 2014 in Menoufia University hospitals on 40 patients with primary varicocele and subfertility. The patients were randomly allocated into two groups of 20 patients each. Patients in group I underwent inguinal varicocelectomy, and patients in group II underwent retroperitoneal varicocelectomy. Results The ages of the 40 patients with suspected appendicitis ranged from 16 to 40 years. The mean age was 25.24 years in group I and 27.15 years in group II. Improvement in semen characteristics was seen in 80% of patients (16 in each group). Hematoma formation was observed in two (10%) cases in group I and in no cases in group II. One (5%) patient of group I had hydrocele formation. No testicular atrophy was noticed in the immediate postoperative period in either group. In two (10%) patients of group II there was no symptomatic relief. In group II there was no patient with symptomatic persistence. Conclusion The inguinal approach is superior to the conventional retroperitoneal approach in the treatment of varicocele, especially with respect to recurrence rate. Using inguinal approach varicocelectomy, identification and preservation of the testicular artery can be easily carried out. However, semen characteristics improved in both groups.
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Different modalities for the management of bilateral cleft lip
Tarek F. A. Keshk, Ayman A Omar, Dalia M Elsaka, Yasser M Elsheikh, Mohammed S AboShaban
January-March 2015, 28(1):107-113
Objectives The aim of this randomized prospective trial was to evaluate the different modalities for the management of bilateral cleft lip including primary and secondary deformities. Background Cleft lip repair will remain the aim of cleft surgeons. The complexity of deformity and the delicate interrelation between muscular arrangement and external lip features require a comprehensive approach for proper management. This study describes technical refinements in the skin design and modifications in the muscle repair in bilateral cleft lip. Materials and methods From January 2012 to April 2014, 16 patients with bilateral cleft lip deformities received surgical treatment in the form of either (group A, n = 10 patients) closure of the primary cleft according to the type and amount of protrusion of the premaxilla or (group B, n = 6 patients) repair of secondary deformities according the presentation. Demographic data, operative time, post, hospital stay, duration of incapacity for work, postoperative complications (infection, wound dehiscence, hypertrophic scar), symmetry, vermillion red alignment, quality of the scar, and patient satisfaction were recorded. Results The overall results were very satisfactory in function and appearance, without major complications. The lip adhesion procedure was performed at the age of 2-8 weeks postnatally, definitive lip closure at the age of 3-6 months (primary repair 10 cases), and secondary repair at the age of 2 years until adulthood (secondary repair six cases). Wound dehiscence occurred in two cases that healed spontaneously without intervention. Conclusion This method of comprehensive primary muscle, soft tissue, and skin reconstruction in bilateral cleft lip addresses the major sites of distortion in the lip, sulcus, and nasal floor, producing a full central segment, prominent philtral ridges, adequate white roll, and thick vermilion with a seam-like median tubercle in addition to a deep gingivo-labial sulcus and alar base symmetry. Nasal deformity postponed with secondary repair.
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Comparative study between 'onlay' and 'sublay' hernioplasty in the treatment of uncomplicated ventral hernia
Ahmed Hosny Ibrahim, Ahmed Sabry El-Gammal, Mostafa Mahmoud Mohamed Heikal
January-March 2015, 28(1):11-16
Objectives The aim of the study was to compare between two techniques of mesh placement in uncomplicated ventral hernias, onlay (mesh on external oblique) versus sublay (mesh in the retromuscular space), to establish the standard technique for treatment of such cases. Background Ventral hernias are commonly encountered in surgical practice. The estimated incidence of ventral hernia is 2-10%. Despite the high frequency of surgical repair, the optimal approach for abdominal ventral hernias is still under discussion. Patients and methods This prospective study included 40 consecutive adult patients with uncomplicated ventral hernia, either primary or secondary. The patients were divided into two groups. Group A (n = 20) was operated upon following the onlay mesh repair technique and group B (n = 20) was operated upon by means of the sublay mesh repair technique. All patients were evaluated as regards operative time and postoperative complications. Results were documented and statistically analyzed. Results In this study, sublay use of the mesh in the treatment of ventral hernia significantly reduced the time to remove the drains (which was longer in the onlay mesh group; P = 0.001), seroma formation after drain removal (which was significantly higher in the onlay mesh group; P = 0.010), and wound infection (which was significantly higher in the onlay mesh group; P = 0.010) in comparison with onlay mesh repair. Conclusion We conclude that retromuscular (sublay) mesh repair is the ideal technique for ventral hernia repair.
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Revascularization versus revascularization and repair in moderate chronic ischemic mitral regurgitation: a randomized trial
Ahmed L Dokhan, Mohamed A Khalil, Mostafa F Abu ollo, Mohamed T Abdulmonem
January-March 2015, 28(1):114-120
Objectives The goal of this study was to determine whether the surgical management of moderate chronic ischemic mitral regurgitation (IMR) is to revascularize only or to revascularize and perform mitral valve repair as well. Background Ischaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodeling due to chronic coronary artery disease. Although there are numerous possible treatment modalities, the management of patients with moderate chronic IMR remains uncertain. Patients and methods Forty patients referred for coronary artery bypass grafting with moderate IMR and an ejection fraction more than 30% were randomized to receive coronary revascularization plus mitral valve repair (20 patients) or revascularization only (20 patients). Survivors were clinically and echocardiographically assessed early postoperatively and at 3 months' follow-up. Results There was no significant difference between the two groups as regards preoperative and demographic data. The operative time, ventilation time, and ICU stay were significantly higher in the repair group. Use of cardiac supports, complications, in-hospital mortality, and ward stay were not statistically significantly different. Postoperative and follow-up echocardiographic data showed no statistically significant difference in left atrial dimension, left ventricular dimension, and function between the two groups. Although the grade of mitral regurgitation showed improvement in both groups, there was significantly higher improvement in the repair group compared with the revascularization-only group. Conclusion Adding mitral repair to coronary revascularization in patients with moderate IMR may improve mitral regurgitation severity without additional risk. Improvement in functional capacity and left ventricular reverse remodeling was observed in both procedures.
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Assessment of left internal mammary artery to left anterior descending flow in composite arterial bypass grafting
Ahmed Labib Dokhan, Yahia Balbaa Anwar Balbaa, Mostafa Farouk Abo olo, Mohamed Sabry Abd Elmotellib Hussien
January-March 2015, 28(1):121-124
Objectives The aim of the study was to achieve arterial myocardial revascularization using the 'Y-graft or T-graft' techniques and to measure intraoperative graft flow by transit-time flowmetry. Background Composite grafting techniques for coronary artery bypass grafts have been widely used. However, it remains unclear whether this technique provides similar blood flow to the left coronary artery. In this study, we evaluated composite grafting techniques by intraoperative measurement graft flow by transit-time flowmetry. Materials and methods Fifty patients who underwent coronary artery bypass grafting during a time period of 24 months were enrolled in this prospective study. All patients received sequential grafting using both internal thoracic arteries and left radial artery joined as a composite Y or T graft. Intraoperative left internal mammary artery (LIMA) flow was measured by transit-time flowmetry. Results This study provided evidence that the LIMA limb of a composite Y or T graft had intraoperative increase in mean flow, and there was statistical significance (P < 0.01) between mean flow with clamping Y or T graft (41.72 ± 15.59 ml/min) and with patent Y or T graft (78.60 ± 29.58 ml/min). Conclusion LIMA has the potential to provide sufficient blood flow to revascularize left coronary system.
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Multiple doses versus single-dose methotrexate protocols for the management of some cases of ectopic pregnancy
Osama A Elkilani, Tarek M Sayyed, Ahmed H Metwalli
January-March 2015, 28(1):250-253
Objective The aim of the study was to compare the efficacy of two methods of administering methotrexate in the treatment of ectopic pregnancy (EP) - multiple-dose methotrexate intramuscular injection and single-dose methotrexate intramuscular injection - in a prospective randomized study. Data analysis Electronic medical research databases were searched from 1982 or from the starting date of each database. The search was performed on 1 March 2013 and included ahead-published printed articles without language restrictions. Study selection The initial search presented 250 articles, of which 30 met the inclusion criteria. The articles were previous trials on methotrexate therapy in the treatment of EP as well as current therapies previously trialed and potential therapies for the near future. Data extraction Studies that had obtained ethical approval, that followed a prospective randomized design, with specific eligibility criteria, used appropriate controls, and with adequate follow-up and defined outcome measures were selected. Data synthesis Although heterogeneity existed in follow-up periods and in reported outcome measures, it was possible to pool the data and perform comparisons by statistical review. Recent findings Early diagnosis of EP allows a conservative medical approach with methotrexate, which is considered the treatment of choice over surgical intervention. This includes the use of methotrexate in a single-dose injection or multiple-dose injections as comparable protocols for treatment of EP. Conclusion Methotrexate is a reliable method for treatment of early unruptured EP either by single-dose methotrexate intramuscular injection or multiple-dose methotrexate intramuscular injection. There are no significant differences in primary treatment success. Single-dose injections have lower side effects compared with multiple-dose injections.
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