Ayman El Nakeeb

To investigate the clinicopathological features and the significance of different prognostic factors which predict surgical overall survival in patients with gastric carcinoma. This retrospective study includes 80 patients diagnosed and treated at gastroenterology surgical center, Mansoura University, Egypt between February 2009 to February 2013. Prognostic factors were assessed by cox proportional hazard model. There were 57 male and 23 female. The median age was 57 years (24-83). One, 3 and 5 years survival rates were 71%, 69% and 46% respectively. The median survival was 69.96 mo. During the follow-up period, 13 patients died (16%). Hospital morbidity was reported in 10 patients (12.5%). The median number of lymph nodes removed was 22 (4-41). Lymph node (LN) involvement was found in 91% of cases. After R0 resection, depth of wall invasion, LN involvement and the number (> 15) of retrieved LN, LN ratio and tumor differentiation predict survival. In multivariable analysis, tumor differentiation, curability of resection and a number of resected LN superior to 15 were found to be independent prognostic factors. Surgery remains the cornerstone of treatment. Tumor differentiation, curability of resection and a number of resected LN superior to 15 were found to be independent prognostic factors. Extended LN dissection does not increase the morbidity or mortality rate but markedly improves long term survival.

To determine predictors of long term survival after resection of hilar cholangiocarcinoma (HC) by comparing patients surviving > 5 years with those who survived < 5 years. This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center, Mansoura University, Egypt between January 2002 and April 2013. All data of the patients were collected from the medical records. Patients were divided into two groups according to their survival: Patients surviving less than 5 years and those who survived > 5 years. There were 34 (14%) long term survivors (5 year survivors) among the 243 patients. Five-year survivors were younger at diagnosis than those surviving less than 5 years (mean age, 50.47 ± 4.45 vs 54.59 ± 4.98, P = 0.001). Gender, clinical presentation, preoperative drainage, preoperative serum bilirubin, albumin and serum glutamic-pyruvic transaminase were similar between the two groups. The level of...

To study the preoperative and postoperative role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients. This is a multicenter retrospective study by reviewing the database of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux en Y gastric bypass, or laparoscopic minigastric bypass) in the period between 2001 June and 2015 August (Jahra Hospital-Kuwait, Hafr Elbatin Hospital and King Saud Medical City-KSA, and Mansoura University Hospital - Egypt). Patients with age 18-65 years, body mass index (BMI) > 40, or > 35 with comorbidities after failure of many dietetic regimen and acceptable levels of surgical risk were included in the study after having an informed signed consent. We retrospectively reviewed the medical charts of all morbidly obese patients. The patients' preoperative data included clinical history including upper digestive symptoms and preoperative full workup including EGD. Only patients whose charts revealed weather they were symptomatic or not were studied. We categorized patients accordingly into two groups; with (group A) or without (group B) upper digestive symptoms. The endoscopic findings were categorized into 4 groups based on predetermined criteria. The medical record of patients who developed stricture, leak or bleeding after bariatric surgery was reviewed. Logestic regression analysis was used to identify preoperative predictors that might be associated with abnormal endoscopic findings. Three thousand, two hundred and nineteen patients in the study period underwent bariatric surgery (75% LSG, 10% LRYDB, and 15% MGB). Mean BMI was 43 ± 13, mean age 37 ± 9 years, 79% were female. Twenty eight percent had presented with upper digestive symptoms (group A). EGD was considered normal in 2414 (75%) patients (9% group A vs 66% group B, P = 0.001). The abnormal endoscopic findings were found high in those patients with upper digestive symptoms. Abnormal findings (one or more) were found in 805 (25%) patients (19% group A vs 6% group B, P = 0.001). Seven patients had critical events during conscious sedation due to severe hypoxemia (< 60%). Rate of stricture in our study was 2.6%. Success rate of endoscopic dilation was 100%. One point nine percent patients with gastric leak were identified with 75% success rate of endoscopic therapy. Three point seven percent patients developed acute upper bleeding. Seventy-eight point two percent patients were treated by conservative therapy and EGD was performed in 21.8% with 100% success and 0% complications. Our results support the performance of EGD only in patients with upper gastrointestinal symptoms. Endoscopy also offers safe effective tool for anastomotic complications after bariatric surgery.

The time interval between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) is a matter of debate. This study was planned to compare early LC versus late LC. This is a prospective randomized study on patients who are presented with concomitant gallbladder and common bile duct stone. The study population was divided into two groups; group (A) managed by early LC within three days after ERCP; and group (B) managed by late LC one month after ERCP. No significant difference between both groups as regards the conversion rate, the degree of adhesion, cystic duct diameter, and intraoperative common bile duct injury or bleeding. Recurrent biliary symptoms were significantly more in delayed LC group in 7 (12.71%) patient versus 1 patient in early LC (P=0.03). No significant difference between both groups as regards the conversion rate. Recurrent biliary symptoms were significantly more in delayed LC while waiting LC. Morbidity was significantly more in delayed LC.

Management of common bile duct stones (CBDS) in patients with borderline CBD presents a surgical challenge. The aim of this study was to compare conservative treatment with endoscopic stone extraction for the treatment of borderline CBD with stones. This prospective randomized controlled trial includes patients with CBDS in borderline CBD (CBD <10 mm) associated with gallbladder stones who were treated with conservative treatment or endoscopic stone extraction followed by laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC). The primary outcome was successful CBD clearance. The secondary outcomes were the overall complications, cost, and hospital stay. LC and IOC revealed complete clearance of CBDS in 48 (96%) cases in the endoscopic retrograde cholangiopancreatography (ERCP) group (52% of patients by ERCP, and 44% of patient passed the stone spontaneously), and in the remaining two patients, the CBDS was removed by transcystic exploration. In the conservative group, LC and IOC revealed complete clearance of CBDS in 90% of cases, and in the remaining 10% of patients, the CBDS was removed by transcystic exploration. Post-ERCP pancreatitis (PEP) is noticed significantly in the ERCP group (2 [4%] versus 8 [16%]; P = .04). The average net cost was significantly higher in the ERCP group. Recurrent biliary symptoms developed significantly in the ERCP group after 1 year (10% versus 0%; P = .02) in the form of recurrent cholangititis and recurrent CBDS. Management of CBDS in patients with borderline CBD represents a surgical challenge. Borderline CBD increases the technical difficulty of ERCP and increases the risk of PEP. Conservative management of CBDS in borderline CBD not only avoids the risks inherent in ERCP and unnecessary preoperative ERCP, but it is also effective in clearing CBDS. The hepatobiliary surgeon should consider a conservative line of treatment in CBDS in borderline CBD in order to decrease the cost and avoid unnecessary ERCP.

The need for routine use of preoperative biliary drainage (PBD) before major liver resection in jaundiced patients has recently been questioned. Our aim was to present our experience of patients with proximal bile duct cancer who undergo major liver resection without PBD and compare these results with patients without biliary obstruction who underwent major liver resection. Eighty six consecutive jaundiced patients underwent major liver resection without PBD. The postoperative outcome was compared to the control group, which was the same size and matched. A case-comparison study. Fifty nine jaundiced patients (69%) and 22 non-jaundiced patients (25%) received blood transfusion (p = 0.04). Fifty-three patients (62%) in the jaundiced group and 17 (19%) in the non-jaundiced patients experienced postoperative complications (p = 0.003). A statistically significant difference could not be detected for mortality (6 vs. 2%) and transient liver failure (10 vs. 3%). Those patients who underwent extended right hemihepatectomy (with future liver remnant <50%) express high morbidity (55 vs. 24%; p = 0.04) and mortality (23 vs. 8%; p = 0.001) compared to the non-jaundiced patients. Major liver resection without PBD leaving a liver remnant of more than 50% is safe in jaundiced patients. However, transfusion requirement and morbidity are higher in jaundiced patients than in non-jaundiced patients.

Aim: The study was undertaken to determine outcome and to identify predictors of success of biofeedback for patients with spastic pelvic floor syndrome. Patients & Methods: The study was done on 50 patients (35 females & 15 males) with a mean age of 30 ± 10 years & a mean duration of constipation of 5 years. History, physical examination & barium enema excluded constipation secondary to organic causes. Then a series of tests of colonic & pelvic floor functions were performed before & after biofeedback treatment: colon-transit time, anorectal manometry ± EMG & defecography. Patients were treated on a weekly basis (average of 7 ± 2 sessions). Parameters included use of cathartics, number of spontaneous bowel movements per week, number of biofeedback sessions, results of anorectal physiology testing & patient satisfaction. Results: The median number of spontaneous bowel movements per week before treatment was zero. Thirty five patients had complete success, 11 patients showed partial s...

Correspondence to: Mohamad El-Hemaly, Email: hemalyma@yahoo.com ... Aim: To present the value of investigative tools especially physiological tests to match the suitable patient for the suitable treatment hoping for cure. ... Methods: 30 patients with SRUS (20 males & 10 ...

... Correspondence to: Hosam Roshdy, Email: hosam.roshdi@yahoo.com Abstract ... although the safety margin was 5 mm by Hallgrimsson P et al, the harmonic device has in some instances been too close to the recurrent laryngeal nerve, eg at the ligament of Berry. ...

Delayed gastric emptying (DGE) is one of the most troublesome complications of pancreaticoduodenectomy (PD). Diabetes mellitus (DM) is one of the risk factors for pancreatic cancer. Moreover, several studies have shown that diabetic patients tend to have a high incidence of upper gastrointestinal symptoms such as nausea, vomiting and DGE. Here, we compared the influence of DM on the incidence of DGE after PD. We retrospectively analysed 67 cases of PD with pancreaticogastrostomy. These patients were categorized into the following two groups: the DM group included patients with DM, and the NDM group included patients without DM. The incidence of DGE was determined and compared between the two groups. In the DM group, 76.5%, 5.9% and 17.6% of the subjects developed classes A, B and C DGE, respectively; the corresponding values in the NDM group were 58%, 22%, and 20%. The incidence of DGE did not differ between the two groups (P < 0.2771). DM does not accelerate DGE in patients who have undergone PD. Preoperative DM does not appear to play a key role in post-operative DGE after PD.

Correspondence to: Ayman El Nakeeb, Email: elnakeebayman@yahoo.com ... Aim: To evaluate functional outcome of transperineal (TP) versus transrectal (TR) repair of rectocele presented with obstructed defecation. Methods: 48 multiparous females with obstructed defecation ...

bstract
PURPOSE:
Anismus is a significant cause of chronic constipation. This study came to revive the results of BFB training and BTX-A injection in the treatment of anismus patients.
MATERIALS AND METHODS:
Forty-eight patients with anismus (33 women; mean age 39.6 +/- 15.9) were included in this study. All patients fulfilled Rome II criteria for functional constipation. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography (EMG) activity of the EAS. All patients had non-relaxing puborectalis muscle. The patients were randomized into two groups. Group I patients received biofeedback therapy, two times per week for about 1 month. Group II patients were injected with BTX-A. Follow-up was conducted weekly in the first month then monthly for about 1 year.
RESULTS:
In the BFB training group, three patients quit before the end of sessions with no improvement; initial improvement was recorded in 12 patients (50%) while long-term success was recorded in six patients (25%). In the BTX-A group, clinical improvement was recorded in 17 patients (70.83%), but the improvement persisted only in eight patients (33.3%). There is a significant difference between BTX-A group and BFB group regarding the initial success, but this significant difference disappeared at the end of follow-up. Manometric relaxation was achieved significantly post-BFB and post-BTX-A injection with no significant difference between the two groups.
CONCLUSIONS:
Biofeedback training has a limited therapeutic effect on patients suffering from anismus. BTX-A injection seems to be successful for temporary treatment of anismus.

Abstract
BACKGROUND:
Improved laparoscopic experience and techniques have made laparoscopic cholecystectomy (LC) feasible options in cirrhotic patients. This study was designed to compare the risk and benefits of open cholecystectomy (OC) versus LC in compensated cirrhosis.
METHOD:
A randomized prospective study, in the period from October 2002 till December 2006, where 110 cirrhotic patients with symptomatic gallstone were randomly divided into OC group (55 patients) and LC group (55 patients).
RESULTS:
There was no operative mortality. In LC group 4 (7.33%) patients were converted to OC. Mean surgical time was significantly longer in OC group than LC group (96.13+17.35 min versus 76.13+15.12) P<0.05, associated with significantly higher intraoperative bleeding in OC group (P<0.01), necessitating blood transfusions to 7 (12.72%) patients in OC group. The time to resume diet was 18.36+8.18 h in LC group which is significantly earlier than in OC group 47.84+14.6h P<0.005. Hospital stay was significantly longer in OC group than LC group (6+1.74 days versus 1.87+1.11 days) P<0.01 with low postoperative morbidity.
CONCLUSION:
LC in cirrhotics is still complicated and highly difficult which associates with significant morbidity compared with that of patients without cirrhosis. However, it offers lower morbidity, shorter operative time; early resume dieting with less need for blood transfusion and reducing hospital stay than OC.

Abstract
AIM:
To study the results for the treatment of symptomatic hemorrhoids using rubber band ligation (RBL) method.
METHODS:
A retrospective study for 750 patients who came to the colorectal unit from June, 1998 to September, 2006, data was retrieved from archived files. RBL was performed using the Mc Gown applicator on an outpatient basis. The patients were asked to return to out-patient clinic for follow up at 2 wk, 1 mo, 6 mo and through telephone call every 6 mo for 2 years).
RESULTS:
After RBL, 696 patients (92.8%) were cured with no difference in outcome for second or third degree hemorrhoids (P = 0.31). Symptomatic recurrence was detected in 11.04% after 2 years. A total of 52 patients (6.93%) had 77 complications from RBL which required no hospitalization. Complications were pain, rectal bleeding and vaso-vagal symptoms (4.13%, 4.13% and 1.33% of patients, respectively). At 1 mo there were a significant improvement in mean SF-36 scores over baseline in five items, while after 2 years there were improvement in all items over baseline, but not significant. No significant manometeric changes after band ligation.
CONCLUSION:
RBL is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an out patient procedure with significant improvement in quality of life. RBL doesn't alter ano-rectal functions.

Abstract
OBJECTIVES:
The objective of this study was to compare the results of partial division of puborectalis (PDPR) versus local botulinum toxin type A (BTX-A) injection in treating patients with anismus.
PATIENTS AND METHODS:
This prospective randomized study included 30 male patients suffering from anismus. Diagnosis was made by clinical examination, barium enema, colonoscopy, colonic transit time, anorectal manometry, balloon expulsion test, defecography, and electromyography. Patients were randomized into: group I which included 15 patients who were injected with BTX-A and group II which included 15 patients who underwent bilateral PDPR. Follow-up was conducted for about 1 year. Improvement was considered when patients returned to their normal habits.
RESULTS:
BTX-A injection achieved initial success in 13 patients (86.7%). However, long-term success persisted only in six patients (40%). This was in contrast to PDPR which achieved initial success in all patients (100%) with a long-term success in ten patients (66.6%). Recurrence was observed in seven patients (53.8%) and five patients (33.4%) following BTX-A injection and PDPR, respectively. Minor degrees of incontinence were confronted in two patients (13.3%) following PDPR.
CONCLUSION:
BTX-A injection seems to be successful for temporary treatment of anismus.

Abstract
BACKGROUND:
This study assesses the safety outcome of early oral feeding and reports on the factors affecting early postoperative feeding after colorectal procedures.
PATIENTS AND METHODS:
Between June 2005 and April 2008, 120 consecutive patients underwent elective colonic anastomosis and were then randomized into two groups. The early feeding group began fluids on the first postoperative day while the regular feeding group was managed in the traditional way - nothing by mouth until the resolution of ileus.
RESULTS:
The majority of patients (75%) tolerated the early feeding. The times to first passage of flatus (3.3+/-0.9 days vs 4.2+/-1.2 days) and stool (4.1+/-1.2 days vs 4.9+/-1.2 days) were significantly quicker in group 1. Hospital stay was also significantly shorter in the early feeding group (6.2+/-0.2 days vs 6.9+/-0.5 days). Operative time and amount of blood loss had an impact on the tolerability of early feeding while age, gender, type of operation and previous abdominal operation had no such impact.
CONCLUSION:
Early oral feeding after colorectal surgery is safe and tolerated by the majority of patients. Operative time and amount of blood loss do, however, have an impact on the tolerability of early feeding.

Abstract
BACKGROUND:
This study was conducted to elucidate the prevalence of Helicobacter pylori in patients with a perforated duodenal ulcer and to determine whether eradication of H. pylori prevent ulcer recurrence following simple repair of the perforation.
PATIENTS AND METHOD:
Eighty-three patients with perforated duodenal ulcer (68 males); mean age was 47.8 years+/-7.2. Antral mucosal biopsies (to determine the status of HP by rapid urease test, culture and histological examination/staining) were obtained during laparotomy by passing a biopsy forceps through the perforation site. H. pylori positive patients who had undergone patch repair were randomized into the eradication group who received amoxicillin, metranidazole plus omperazole and the control group was given omeprazole alone. Follow-up endoscopy and antral biopsies were performed at 8 weeks, 16 weeks and 1 year to show ulcer healing and determine H. pylori state.
RESULTS:
Of 77 patients in the study, 65 patients (84.8%) had H. pylori. These patients were randomly divided into the triple therapy group (34 patients) and the control group (31 patients). Eradication of H. pylori was significantly higher in the triple therapy group than the control group and initial ulcer healing was significantly better in the eradication group. After 1 year, ulcer recurrence was (6.1%) in the eradication group vs. (29.6%) in the control group (P=0.001).
CONCLUSION:
H. pylori was present in a high proportion of patients with duodenal ulcer perforation. Eradication of H. pylori after simple closure of a perforated duodenal ulcer reduced the incidence of recurrent ulcer.

Abstract
BACKGROUND:
Hypertensive anal canal is frequently known to be associated with the presence of anal fissure. Based on clinical experience, we hypothesized that idiopathic anal sphincter hypertonia was a condition equivalent to anal fissure, and therefore, it could be treated the same way.
PATIENT AND METHODS:
Sixty-three patients complaining of anal pain without any anal pathology and ten healthy volunteers were examined. All patients underwent clinical evaluation, neurological examination, anorectal manometry, and measurement of pudendal nerve terminal motor latency. All patients with hypertensive anal canal were randomized into three groups. Group I (surgical group) underwent closed lateral sphincterotomy (LS), group II using nitroglycerine ointment (GTN), and group III received injection of botulinum toxin in internal sphincter. Post-procedures data were recorded at follow-up period.
RESULTS:
The mean resting anal pressure (MRAP) was significantly higher in the patient group (114.6 +/- 7.4 mmHg) than control group (72.5 +/- 6.6 mmHg, P < 0.001). Anal pain is the main presenting symptoms aggravated by defecation and not relived by analgesics or local anesthetics. After LS, pain visual analogue scale decreased significantly at follow-up period than after chemical sphincterotomy using GTN or BTX (P = 0.001). There was a significant decrease in MRAP postoperatively from 114.6 +/- 7.4 to 70.8 +/- 5.5 mmHg than after using GTN or BTX (P = 0.03).
CONCLUSION:
Idiopathic hypertensive anal canal is a fact and already exists presented by anal pain aggravated by defecation. It can be managed safely by closed lateral sphincterotomy, but chemical sphincterotomy had a minor role in its management.

Abstract
BACKGROUND:
Many studies have shown that gastrografin can be used for diagnosis of adhesive small bowel obstruction (ASBO) and for assessing the need for surgical intervention. However, several studies have reported conflicting results. Therefore, the aim of this study is to assess the diagnostic and therapeutic effect of gastrografin in ASBO.
PATIENTS AND METHODS:
Altogether, 110 patients with ASBO were randomized into control and gastrografin groups. In the gastrografin group, 100 mL of the dye was administered through a nasogastric tube. Obstruction was considered complete if the contrast failed to reach the colon on the 24-h film. Patients with gastrografin in the colon within 24 h after dye administration were considered as partially obstructed, and were submitted to nonoperative treatment. The patients were operated on if they developed signs of strangulation or failed to improve within 48 h.
RESULTS:
The overall operative rate was 14.5% in gastrografin group versus 34.5% in control group, P=0.04. The time from admission to resolution of symptoms was significantly lower in gastrografin group (19.5 versus 42.6 h, P=0.001), and the length of hospital stay was shorter in gastrografin group (3.8 versus 6.9 d 0.002), and in nonoperative patients (3.1 versus 5.1 days). Sensitivity, specificity, positive predictive value, and negative predictive value for gastrografin follow-through as an indicator for operative treatment of ASBO were 87.5%, 100%, 100 % , and 97.9%, respectively.
CONCLUSIONS:
Oral gastrografin helps in the management of ASBO. Oral gastrografin is safe and reduces the operative rate and time of resolution as well as hospital stay.
Copyright 2010 Elsevier Inc. All rights reserved.

bstract
BACKGROUND/AIMS:
The usefulness of preoperative CEA in CRC remains controversial as regards its biological function, and its use in the diagnosis, prognosis, and management and follow up of CRC patients. the aim of this study was to provide a critical and updated study for the value of CEA in CRC.
METHODOLOGY:
From January 2000 to June 2005, a prospective randomized study involving 200 CRC patients for whom curative resection was performed, another 100 healthy persons as a control group was included. Basal CEA using chemilumescence technique and routine follow up were done.
RESULTS:
(1) The mean basal CEA in CRC patients (17.3 ng% +/- 1.67) was significantly higher than control (3.41 ng% +/- 1.1). (2) A significant linear association between basal CEA and Dukes' classes was evident with the mean basal CEA for Dukes' A, B, C were 7.8, 12.7, 25.8 respectively (expressed as ng%). (3) The validity of basal CEA in primary CRC diagnosis was highly positive (sensitivity 80%--PPV 86.95%--accuracy 73.66%), with hig her efficacy in advanced disease detection (sensitivity 93%--NPV 7%--accuracy 84.5%--odds ratio 30.3) and negative exclusion power for DFS prediction (specificity 13.84%). (4) The basal CEA was a discriminate factor in colorectal prognosis - B value (3.74). (5) Patients with CEA < or =5 ng% had better DFS (15%) and DFT (23.6 months) than those with CEA > 5 ng% as they had DFS (33.75%) and DFT (18.48 months). (6) Basal CEA above 15 ng% had a significant shift in the cumulative hazard of recurrence.
CONCLUSION:
The CEA is a metastasis potentiator. The high serum CEA in CRC screening programs should be considered a marker of malignancy especially in patients with appropriate symptoms. The preop CEA in CRC patients identifies subsets with favorable, indolent and uneven biological behavior (< or =5 ng%, < or =15 ng%, > 15 ng% respectively). Moreover, the addition of preop CEA level to conventional staging forms a strong prognostic tool and supplies adopted practice guideline initiative for follow up and therapy in CRC.

Abstract
BACKGROUND:
Improved laparoscopic experiences have made laparoscopic cholecystectomy (LC) feasible options for cirrhotic patients. This study aimed to compare the traditional method for LC with LC using the Harmonic scalpel in terms of safety and efficacy for cirrhotic patients.
METHODS:
In this study, group A (60 patients) underwent LC by the traditional method (TM) with clipping of both the cystic duct and artery and dissection of the gallbladder by diathermy, and group B (60 patients) had LC performed using Harmonic scalpel (HS) closure and division of both the cystic duct and artery with dissection of the gallbladder by the HS. The perioperative data were recorded.
RESULTS:
The operation with the Harmonic scalpel was performed in less time than TM (45.17 ± 10.54 vs. 69.71 ± 13.01 min; p = 0.0001). The intraoperative blood loss was significantly more with TM (133 ± 131.13 l vs. 70.13 ± 80.79 ml; p = 0.002). The conversion rate was 5% with TM and 3.3% with HS (p = 0.65). The incidence of gallbladder peroration was lower in the HS group (10% vs. 18.3%; p = 0.03). Bile leak was encountered in 1.7% with HS and 3.3% with TM (p = 0.45). The visual analog scale (VAS) for pain with HS on postoperative day 1 was (3.07 ± 2.02 vs. 4.4 ± 2.11 (p = 0.001).
CONCLUSION:
For cirrhotic patients, LC still is more complicated and difficult than for patients without cirrhosis. The Harmonic scalpel provides complete hemobiliary stasis and is a safe alternative to the standard clipping of the cystic duct and artery for cirrhotic patients. It offers a shorter operative duration and less blood loss.

Abstract
BACKGROUND:
High transphincteric perianal fistula represents a technical challenge for surgical management. We compared the effects of partial rectal wall advancement flap versus the mucosal advancement flap in the treatment of high transphincteric perianal fistula in a randomized study in patients with anal fistula.
PATIENTS AND METHOD:
Consecutive patients treated for transphincteric anal fistula at our institution were evaluated for inclusion. Participants were randomly allocated to receive Group I: Fistulectomy, closure of internal sphincter and rectal advancement flap includes mucosa, submucosa, and circular muscle layer sutured 1 cm below the level of internal opening or Group II: The same as group one but the flap includes only mucosa and submucosa. Study variables included fistula closure rate, continence, morbidity, postoperative pain, hospital stay and quality of life.
RESULTS:
Forty patients with high transphincteric perianal fistula were randomized and completed the study. Operative time was 31.6 +/- 6.8 min in group I, and 29.4 +/- 4.7 min in group II (P = 0.783). Hospital stay was significantly more in group 2 (96.35 +/- 9.5 vs. 105.8 +/- 13.23) (P = 0.014) Immediate postoperative complications, occurred in one patients (5%) exposed to disruption in group I and 6 patients (30%) in group II. Recurrence occurred in 2 patients (10%) in the group I and 8 patients (40%) in group II. Two patients (10%) in group I developed incontinence for flatus and no patients in the group II develop such complication.

Abstract
PURPOSE:
Anal stenosis represents a technical challenge for surgical management. We compared the effects of house flap, rhomboid flap, and Y-V anoplasty procedures in a randomized study in patients with anal stenosis.
METHODS:
Consecutive patients treated for anal stenosis at our institution were evaluated for inclusion. Participants were randomly allocated to receive house flap, rhomboid flap, or Y-V anoplasty. Follow-up visits were after 1 week, 1 month, 6 months, and 1 year. Study variables included caliber of the anal canal (measured with a conical calibrator), clinical improvement, patient satisfaction (visual analog scale), incontinence (Pescatori incontinence scale), and quality of life (GI Quality of Life Inventory).
RESULTS:
: Sixty patients with anal stenosis were randomized and completed the study. Operative time was 62 +/- 10 minutes for house flap, 44 +/- 13 minutes for rhomboid flap, and 35 +/- 9 minutes for Y-V anoplasty (P = .042). At 1 year, anal caliber was 23.9 +/- 2.33 mm for house flap, 18.1 +/- 2.05 mm for rhomboid flap, and 16.4 +/- 2.05 mm for Y-V anoplasty (P = .04), with a highly significant increase for the house flap (P = .001). The groups differed significantly regarding clinical improvement at 1 month (95% for house flap, 80% for rhomboid flap, and 65% for Y-V anoplasty, P = .01) and differences persisted at 1 year. Significant differences were seen among groups at 1 year in GI Quality of Life Inventory scores (P = .03), with significant improvement only for the house flap (P = .01).
CONCLUSION:
Anal stenosis can be effectively managed with the house flap procedure, with the sole disadvantage of longer operative time. Although all 3 procedures are simple and easy to perform, the house flap appears to produce the greatest clinical improvement, patient satisfaction, and improvement in quality of life, with the fewest complications.

Abstract
PURPOSE:
This study came to compare the results of biofeedback retraining biofeedback (BFB), botulinum toxin botulinum type A (BTX-A) injection and partial division of puborectalis (PDPR) in the treatment of anismus patients.
PATIENTS AND METHODS:
Consecutive patients treated for anismus fulfilled Rome II criteria for functional constipation at our institution were evaluated for inclusion. Participants were randomly allocated to receive BFB, BTX-A injection, and PDPR. All patients underwent anorectal manometry, balloon expulsion test, defecography, and electromyography activity of the anal sphincter. Follow up was conducted weekly in the first month then monthly for about 1 year. Study variables included clinical improvement, patient satisfaction, and objective improvement.
RESULTS:
Sixty patients with anismus were randomized and completed the study. The groups differed significantly regarding clinical improvement at 1 month (50% for BFB, 75%BTX-A injection, and 95% for PDPR, P = 0.006) and differences persisted at 1 year (30% for BFB, 35%BTX-A injection, and 70% for PDPR, P = 0.02). Constipation score of the patients significantly improved postPDPR and BTX-A injection. Manometric relaxation was achieved significantly in the three groups.
CONCLUSION:
Biofeedback retraining has a limited therapeutic effect, BTX-A injection seems to be successful for temporary treatment but PDPR is found to be an effective with lower morbidity in contrast to its higher success rate in treating anismus.

Abstract
BACKGROUND:
Division of lymphatic vessels during varicocelectomy could lead to hydrocele formation and decrease in testicular function due to testicular edema. We determined if the use of methylene blue combined with optical magnification reduces the incidence of post-varicocelectomy hydrocele.
METHODS:
Consecutive patients treated for varicocele at our institution were evaluated for inclusion. Participants were randomly allocated to receive either subinguinal varicocelectomy after 2 ml intratunical space injection of methylene blue and group 2 in whom no mapping technique was adopted during subinguinal varicocelectomy. After surgery, the patients were assessed at 2 weeks, 6 and 12 months for hydrocele, testicular edema, varicocele recurrence, atrophy, pain or other complications with mean follow-up was 15 ± 7 months.
RESULTS:
Eighty patients with varicocele were randomized and completed the study. There were no intra complications in either group. In group (1) no patient had a hydrocele after surgery. By contrast, in group (2) there were four cases of secondary hydrocele (10%; P = 0.041)); no testicular hypertrophy was observed following lymphatic sparing surgery; One patient in each group had varicocele recurrence. Pregnancy was reported in 30 patients (37.5%) during the follow-up period, 17 of them (42.5%) were group (1) difference was not significantly different among both groups.
CONCLUSIONS:
Subinguinal varicocelectomy using combination of optical magnification and lymphatic staining (methylene blue) offers simple and quick preservation of the draining lymphatic vessels and avoids secondary hydrocele formation.

Abstract
BACKGROUND:
Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence.
OBJECTIVE:
We compared conventional lateral internal sphincterotomy, V-Y advancement flap, and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure.
PATIENTS:
Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion. Participants were randomly allocated to receive conventional sphincterotomy (GI), V-Y advancement flap (GII), or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).
MAIN OUTCOME MEASURES:
The primary outcome measure was the incontinence rate; secondary outcomes included healing rate, operative time, anal manometery, and recurrence rate.
RESULTS:
One hundred fifty patients with chronic anal fissure were randomized. Healing rate after 1 year was 84% in GI, 48% in GII, and 94% in GIII, respectively (P = 0.001). The recurrence rate was 4% in G1, 22% in GII, and 2% in GIII (P = 0.01). Incontinence rate was 14% in GI, 0% in GII, and 2% in GIII (P = 0.03).
CONCLUSION:
Although all three procedures are simple and easy to perform, tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate, with the fewest complications and less rate of recurrence.

Abstract
BACKGROUND:
Rectal prolapse is a distressing and socially disabling condition. controversy exists regarding the preferred surgical technique for the treatment of complete rectal prolapse.
OBJECTIVE:
We compared Delorme operation alone or with postanal repair and levatroplasty in treating complete rectal prolapse.
METHODS:
Consecutive patients treated for rectal prolapse at our colorectal unit were evaluated for inclusion. Participants were randomly allocated to receive Delorme operation only (GI), or Delorme operation with postanal repair and levatorplasty (GII).
MAIN OUTCOME MEASURES:
The primary outcome measure was recurrence rate; secondary outcomes included improvement of constipation, incontinence, operative time, anal manometery and postoperative complications.
RESULTS:
Eighty-two consecutive patients with rectal prolapse were randomized. There was a significant difference between the two groups with longer operative time in group II. Recurrence rate after one year was (14.28% in GI, and 2.43% in GII, respectively (P = 0.043). Constipation improved in group I & II but there was a significant difference in constipation scores postoperatively between the two groups. There was improvement in continence mechanism in both groups postoperatively but being higher in group II and this produce a significant statistical difference (0.004). Mean satisfaction score was significantly higher in group II than group I. Both groups succeed to produce a significant change in resting and squeeze pressure before & after the operation.
CONCLUSIONS:
Delorme operation seems to be an effective procedure for treating complete rectal prolapse especially if combined with postanal repair and levatorplasty.

Abstract
BACKGROUND:
This study aimed to compare the short-term outcomes of single-access laparoscopic cholecystectomy (SALC) and conventional laparoscopic cholecystectomy (CLC).
METHODS:
In a prospective study, patients with symptomatic cholelithiasis were randomized to SALC or CLC with follow-up at 1 week, 1 and 6 months. The primary end point of this study was to assess the total outcomes of quality of life using the EuroQoL EQ-5D questionnaire. The secondary end points were postoperative pain, analgesia requirement and duration of use, operative time, perioperative complications, estimated blood loss, hospital stay, cosmesis outcome, and number of days required to return to normal activities.
RESULTS:
A total of 269 patients were prospectively randomized into two groups (125 in each group after excluding 19 patients for various reasons). The SALC procedure was done safely without intraoperative or major postoperative complications. In four SALC patients, an extra epigastric port was inserted to enhance exposure. There was no open conversion in either group. SALC patients reported better results among four of the EuroQoL EQ-5D dimensions (mobility, self-care, activity, and pain/discomfort) at 1 week after surgery, an improved pain profile at 4, 12, and 24 h, better cosmetic outcome at 1 and 6 months (P ≤ 0.01), shorter duration of need for analgesia (P ≤ 0.02), and earlier return to normal activities (P ≤ 0.026). Operative times, hospital stay, QOL at 1 and 6 months postoperatively, and estimated blood loss were similar for both procedures.
CONCLUSION:
This study supports other studies that show that SALC is a feasible and promising alternative to traditional laparoscopic cholecystectomy in selected patients with better cosmesis, QOL, and improved postoperative pain results, and it can be performed with the existing laparoscopic instruments.

Abstract
BACKGROUND/AIM:
Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts.
PATIENTS AND METHODS:
Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed.
RESULTS:
Eighty-one patients had true pancreatic cyst. The mean age was 47 ± 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men (P = 0.04), older age (0.0001), cysts larger than 3 cm in diameter (P = 0.001), presence of solid component (P = 0.0001), and cyst wall thickening (P = 0.0001). The majority of patients with malignancy were symptomatic (26/28, 92.9%). The symptoms that correlated with malignancy included abdominal pain (P = 0.04) and weight loss (P = 0.0001). Surgical procedures were based on the location and extension of the lesion.
CONCLUSION:
The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst.
PMID: 23319038 [PubMed - indexed for MEDLINE] PMCID: PMC3603490 Free PMC Article

Abstract
BACKGROUND:
Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers.
METHODS:
This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected.
RESULTS:
A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m(2) (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture.
CONCLUSIONS:
Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.

Abstract
BACKGROUND:
Solid pseudopapillary tumour (SPT) of the pancreas is a rare neoplasm of low malignant potential. The pathogenesis and guidelines for its treatment remain unclear. This study was designed to evaluate the diagnosis, surgical treatment and prognosis of SPT.
STUDY DESIGN:
A retrospective study during the period between January 1995 to October 2012.
PATIENTS AND METHOD:
Cases with SPTs treated at our institution were reviewed. Demographic data, clinical manifestations, radiological, surgical, and pathological records were reviewed for patients with SPT.
RESULTS:
Twenty four patients with SPT were identified (22 women and 2 men with a mean age 24.83 ± 8.66 (12-52 years). The tumour was located in the head in (50%) and in the body (8.3%) and in the tail (41.7%). The mean size was 9.2 ± 5.3 (3-25 cm). The main clinical presentation was abdominal pain in (83.3%). All 24 patients had curative resection including pancreaticoduodenectomy (50%), central pancreatectomy (8.3%) and distal pancreatectomy (41.7%). Sex, age, symptoms, tumour size, CT image and tumour markers were not significant clinical factors to predict SPT with malignant behavior. The recurrence rate was (8.3%) after 5 years postoperatively. No hospital mortality, all patients except 2 patients (8.3%) were alive at follow up period. The estimated 1, 3, and 5 year survival rate was 95%, 95%, and 88%.
CONCLUSION:
SPT are rare neoplasms with malignant potential. Aggressive surgical resection is needed even in presence of local invasion, and also for recurrence as patients had a good long term survival.

Abstract
BACKGROUND/PURPOSE:
Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic benign gallbladder disease. The identification of factors that reliably predict the need to convert LC to open cholecystectomy (OC) would help with patient education and counseling.
METHODS:
Between January 2000 and December 2009, 4,698 patients underwent cholecystectomy. LC was attempted in 4,434 patients (94.4%) and OC from the start was performed in 264 patients (5.6%). The causes for conversion were evaluated. The change in conversion rate between 2000 and 2004 and between 2005 and 2009 was analyzed. Factors predictive of conversion were identified by univariate and multivariate analysis.
RESULTS:
Conversion to OC from an initial LC approach was required in 234 patients (5.3%). The main cause for conversion was dense adhesions (54.7%). Independent risk factors in multivariate analysis were male gender (p < 0.001), increased age (p < 0.001), a history of previous upper abdominal surgery (p < 0.001), a WBC count >9 × 10(3)/μl, and urgently indicated cholecystectomy (p <0.001). The conversion rate decreased significantly from 6.7 to 3.6% over the two time intervals (p < 0.001).
CONCLUSIONS:
Those at highest risk for conversion are elderly male patients with prior abdominal surgery who present emergently with laboratory evidence of biliary inflammation.

Abstract
AIM:
To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis.
METHODS:
We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient's score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate.
RESULTS:
Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT.
CONCLUSION:
Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Abstract
OBJECTIVES:
The optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD.
METHODS:
Consecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions.
RESULTS:
Ninety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320 min versus 300 min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6 g/dl in the IRPJ group and 3.3 g/dl in the PG group (P = 0.001).
CONCLUSIONS:
Isolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.

Abstract
BACKGROUND:
Obesity is a growing worldwide epidemic. There is association between obesity and pancreatic cancer risk. However, the impact of obesity on the outcome of pancreatoduodenectomy (PD) is controversial. The aim of this study was to elucidate effect of obesity on surgical outcomes of PD.
STUDY DESIGN:
A case-control study.
PATIENT AND METHODS:
We retrospectively studied all patients who underwent PD in our center between January 2000 and June 2012. Patients were divided into two groups; Group A (patients with BMI <25) and Group B (patients with BMI > 25). Preoperative demographic data, intraoperative data, and postoperative details were collected.
RESULTS:
Only 112/471 patients (25.9%) had BMI > 25. The median intraoperative blood loss was more in overweight patients (P = 0.06). The median surgical time in group B was significantly longer than that in group A (P = 0.003). The overall incidence of complications was higher in the overweight group (P = 0.001). The severity of complications was also higher in the overweight group (P = 0.0001). Postoperative pancreatic fistula (POPF) (P = 0.0001) and hospital mortality (P = 0.001) were significantly higher in overweight patients. Oral intake was significantly delayed in overweight patients in comparison to normal weight group (P = 0.02). Postoperative stay was significantly longer in overweight patients (P = 0.0001).
CONCLUSION:
PD is associated with an increased risk of postoperative morbidity in overweight patient. Overweight patients must not be precluded from undergoing PD. However, operative techniques and pharmacological prophylaxis to decrease POPF should be considered in overweight patients.

Abstract
BACKGROUND:
Laparoscopic sleeve gastrectomy (LSG) is a surgical technique that treats morbid obesity.
METHODS:
Consecutive patients with morbid obesity treated by LSG at our department were evaluated. Patients enrolled in the study were randomized into group I (LSG begins the division 2 cm from the pylorus) and group II (LSG begins the division 6 cm from the pylorus). The primary outcome measure was the percent of excess weight loss (% EWL); secondary outcomes included postoperative morbidity and mortality and improvement of comorbidity.
RESULTS:
One hundred five patients (79 (75.2 %) were females) were randomized into two groups of (GI) 52 patients and (GII) 53 patients. In group I, the mean % EWL was 51.8 ± 13.9, 63.8 ± 16.1 and 71.8 ± 12; however, in group II, the mean % EWL was 38.3 ± 10.9, 51.9 ± 13.6 and 61 ± 11.1 at 6, 12, and 24 months, respectively (P = 0.0001, 0.0001, 0.003). There was weight regain after 2 years in five patients in group II and only one patient in group I (P = 0.09). There was no significant difference between both group as regards gastric leakage, vomiting or GER. There was significant improvement in comorbidity after LSG in both groups, but no significant difference between them. Hospital mortality occurred in group II in one case as a result of gastric leakage.
CONCLUSIONS:
LSG is a safe and effective procedure with good short-term outcome. Increasing the size of the resected antrum is associated with better weight loss without increasing the rate of complications significantly.

Abstract
BACKGROUND:
Surgical resection is the only hope for patients with cholangiocarcinoma (CC). This study is designed to assess the impact of cirrhosis on the outcome of surgical management for CC.
PATIENT AND METHODS:
We retrospectively studied all patients who underwent surgical resection for hilar CC. Group I (patients with cirrhotic liver) and Group II (patients with non-cirrhotic liver). Preoperative demographic data, intra-operative data, and postoperative details were collected.
RESULTS:
Only 102/243 patients (41.9%) had cirrhotic liver. Caudate lobe resection was more frequently performed in the non-cirrhotic group (P = <0.001). There was no difference between both groups regarding intraoperative blood loss and the need for blood transfusion. The median postoperative stay was higher in the cirrhotic group (P = 0.063). The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group (P = <0.001). Cirrhosis was associated with significantly lower overall survival (P = <0.001).
CONCLUSION:
Patients with concomitant liver cirrhosis and hilar CC should not be precluded from surgical resection and should be considered for resection at high volume centers with expertise available to manage liver cirrhosis. The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group.

Abstract
BACKGROUND:
Gastroesophageal reflux disease (GERD) is a common public health problem. Medical treatment remains the first line of treatment of GERD. Failure of medical treatment may occur in up to 45% of GERD patients. This study aims to evaluate the outcome of laparoscopic Nissen fundoplication (LNF) as a means of antireflux surgery in patients with poor response to anti-reflux medication.
PATIENTS AND METHODS:
This is a prospective study of patients who underwent LNF in the period between January 2000 and December 2010 in the Gastrointestinal Surgical Center, Mansoura University, Egypt. Patients were assessed preoperatively and postoperatively, after 1 year, by clinical examination, esophagogastroscope, barium esophagography, esophageal manometry and 24-h pH monitoring. Patient satisfaction after surgery was also graded through a questionnaire.
RESULTS:
The study population was 370 patients. 296 patients were good responders to proton pump inhibitors (PPI) while 74 patients were PPI non-responders. Preoperatively, atypical reflux symptoms were significantly more in PPI non-responders (P = 0.006). On follow-up, PPI responders significantly reported relief of heartburn (P = 0.01) and regurgitation (P = 0.04). Patient satisfaction was more in PPI responders (P = 0.04). Both groups were comparable regarding anatomical and functional assessment. Integrity of the wrap was higher in PPI responders (P = 0.04).
CONCLUSION:
PPI non-responders should not be precluded from LNF. Thorough assessment is mandatory to confirm GERD diagnosis. A substantial proportion of PPI failures show good response to LNF but significantly than clinical response in PPI responders. Increased likelihood of poor outcome after surgery should be discussed with the patient.

Abstract
BACKGROUND/AIMS:
Pancreatic head cancer is considered to have the worst prognosis of the periampullary carcinomas. The clinicopathological features of uncinate process pancreatic cancer are poorly published.
METHODOLOGY:
We retrospectively studied patients who underwent pancreaticodudenectomy (PD) for pancreatic head adenocarcinoma. This study included three groups of patients. Group A patients with pure pancreatic head carcinoma (PPHC), group B patients with combined head and uncinate process carcinoma (CPHUC) and group C patients with pure uncinate process carcinoma (PUPC). Preoperative, intraoperative and postoperative variables were collected.
RESULTS:
The study included 157 patients. Jaundice was the most common presenting symptoms in PPHC and CPHUC. Abdominal pain was the most common presenting symptoms in PUPC. The mean common bile duct (CBD) and pancreatic duct diameters were significantly smallest in PUPC group (P=0.0001). The venous invasion was significantly observed more in PUPC group and vascular resection was done in 50% of cases. The number of patients with microscopically residual tumor was significantly highest in PUPC group after PD than in other two groups (P=0.001). Recurrence rate occurred in 54.2% in PUPC group, 34.8% in CPHUC group and 22.7% in PPUC group after PD (P=0.007). The median survival was 19 months in PPHC groups, 16 months in CPHUC group, 14 months in PUPC group (P= 0.02).
CONCLUSIONS:
PUPC presented with abdominal pain with more vascular infiltration. The recurrence rate was common after PD for uncinate process carcinoma especially locoregional recurrence and the overall survival rate was found to be lower for PUPC.

Abstract
BACKGROUND:
Pancreatic cancer is considered to have the worst prognosis of the periampullary carcinomas. This retrospective study was to determine prognostic factors for survival after pancreaticoduodenectomy in patients had pancreatic carcinoma.
METHODS:
We retrospectively studied all patients who underwent PD for pancreatic adenocarcinoma originating from the head, neck or uncinate process from January 1996 to January 2011 in our center. Preoperative variables, intraoperative variables and postoperative variables were collected.
RESULTS:
The study included 480 patients (282 males and 198 females with a median age of 53 years. At the time of analysis, 180 (37.5%) patients were still alive. The median survival was 19 months. This corresponded to a 1-, 3-, and 5-year actuarial survival of 44 %, 20%, and 15% respectively. Mass size less than 2 cm (P=0.0001), lymph node ratio (P=0.0001), safety margin (P=0.0001), perineural, perivascular infiltration, age above 60 years (P=0.03), gender, preoperative bilirubin, SGPT, liver status, pre and postoperative CEA, CA19- 9 (P=0.0001) were significant predictors of survival.
CONCLUSION:
Mass size less than 2 cm, lymph node ratio, safety margin, perineural, perivascular infiltration, age above 60 years, gender, liver status, pre and postoperative CEA, CA19-9 are important predictors of survival in patients undergoing PD for pancreatic cancer.

Abstract
AIM:
To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS).
METHODS:
Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS.
RESULTS:
Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipple's operation was scheduled.
CONCLUSION:
The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.

Abstractin English, Turkish
OBJECTIVE:
Egypt is one of the hot spots in the international map of Hepatocellular carcinoma (HCC), which is where hepatitis C virus (HCV) infection is the major risk factor in development of HCC (80%). Due to low organ donation rates and lack of deceased liver transplantation, hepatic resection is the main line of treatment for HCC patients with sufficient liver reserve. We introduce our experience with patients who had HCV related HCC who underwent hepatic re-section to determine various predictors of tumour recurrence in this group. This is the first study to come from a country where chronic HCV hepatitis is endemic.
MATERIALS AND METHODS:
This is a retrospective cohort study of 208 cases of HCC in hepatitis C virus positive patients with cirrhotic livers who underwent first-time liver resection, in Gastroenterology Surgical Centre, Mansoura University, Egypt during the period from January 2002 to December 2011. Shapiro-Wilk test was used to assess normality of data. Predictors of HCC recurrence were assessed by bivariate correlation tests, univariate analysis using the chi-square and t-test and binary logistic regression analysis. A P value <0.05 was considered statistically significant.
RESULTS:
Tumour recurrence occurred in 88 patients (42.3%). Most of the recurrences occurred within the first year 55 patients (62.5%). The most common site for recurrence was the liver (n=68, 77.3%). Based on the univariate analysis; significant variables predicting tumor recurrence were alpha feto-protein (AFP), blood transfusion, multi-focality, cut margin, microvascular invasion, lack of capsule, tumour grade and stage. Based on multivariate analysis, the main variables predicting tumor recurrence were blood transfusion, cut margin, tumour capsule and microvascular invasion.
CONCLUSION:
Although the predictors of recurrence are the same for both HBV and HCV related HCC, the rate and aggressiveness of recurrence are higher in HCV related HCC.

Abstract
BACKGROUND:
The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD.
METHODS:
Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions.
RESULTS:
One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively.
CONCLUSION:
Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS.

Abstract
BACKGROUND:
Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD). This study was designed to evaluate perioperative risk variables for DGE after PD and analyze the factors that predict its severity.
PATIENTS AND METHOD:
Demographic data, preoperative, intraoperative, and postoperative variables were collected.
RESULTS:
A total of 588 consecutive patients underwent PD. One hundred and five patients (17.9 %) developed DGE of any type. Forty-three patients (7.3 %) had a type A, 53 patients (9.01 %) had DGE type B, and the remaining nine patients (1.5 %) had DGE type C. BMI > 25, diabetes mellitus (DM), preoperative biliary drainage, retrocolic reconstruction, type of pancreatic reconstruction, presence of complications, postoperative pancreatic fistula (POPF), and bile leaks were significantly associated with a higher incidence of DGE. Thirty-three (31.4 %) patients were diagnosed as primary DGE, while 72 (68.5 %) patients had DGE secondary to concomitant complications. Type B and C DGE were significantly noticed in secondary DGE (P = 0.04). Hospital stay was significantly shorter in primary DGE.
CONCLUSION:
Retrocolic GJ, DM, presence of complications, type of pancreatic reconstruction, and severity of POPF were independent significant risk factors for development of DGE. Type B and C DGE were significantly more in secondary DGE.