A Biotechnological Approach for the Production of Pharmaceutically Active Human Interferon-α from Raphanus sativus L. Plants

Human interferon (IFN) is a type of cytokine that regulates the immune system’s response to viral and bacterial infections. Recombinant IFN-α has been approved for use in the treatment of a variety of viral infections as well as an anticancer medication for various forms of leukemia. The objective of the current study is to produce a functionally active recombinant human IFN-α2a from transgenic Raphanus sativus L. plants. Therefore, a binary plant expression construct containing the IFN-α2a gene coding sequence, under the regulation of the cauliflower mosaic virus 35SS promoter, was established. Agrobacterium-mediated floral dip transformation was used to introduce the IFN-α2a expression cassette into the nuclear genome of red and white rooted Raphanus sativus L. plants. From each genotype, three independent transgenic lines were established. The anticancer and antiviral activities of the partially purified recombinant IFN-α2a proteins were examined. The isolated IFN-α2a has been demonstrated to inhibit the spread of the Vesicular Stomatitis Virus (VSV). In addition, cytotoxicity and cell apoptosis assays against Hep-G2 cells (Human Hepatocellular Carcinoma) show the efficacy of the generated IFN-α2a as an anticancer agent. In comparison to bacterial, yeast, and animal cell culture systems, the overall observed results demonstrated the efficacy of using Raphanus sativus L. plants as a safe, cost-effective, and easy-to-use expression system for generating active human IFN-α2a.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases

AIM

To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors.

METHODS

This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017).

RESULTS

The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.

CONCLUSION

Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity

AIM

To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity.

METHODS

This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected.

RESULTS

The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP.

CONCLUSION

PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

How does epidemiological and clinicopathological features affect survival after gastrectomy for gastric cancer patients-single Egyptian center experience

AIM: To investigate the clinicopathological features and the significance of different prognostic factors which predict surgical overall survival in patients with gastric carcinoma.

METHODS: 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.

RESULTS: 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.

CONCLUSION: 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.

Malondialdehyde, superoxide dismutase and melatonin levels in gingival crevicular fluid of aggressive and chronic periodontitis patients

BACKGROUND

The aim of this study was to investigate malondialdehyde (MDA), superoxide dismutase (SOD) and melatonin levels in the gingival crevicular fluid (GCF) of patients with chronic periodontitis (CP) and generalized aggressive periodontitis (GAgP) as biomarkers for oxidative stress.

METHODS

The study comprised 65 subjects: 15 healthy individuals, 25 CP patients and 25 GAgP patients. Plaque index, gingival index, pocket depth, clinical attachment level measurements and GCF samples were obtained from all subjects. MDA, SOD and melatonin levels were determined utilizing enzyme-linked immunosorbent assay.

RESULTS

GCF-MDA levels were significantly higher in the GAgP group compared to the CP and control groups (p < 0.001) and significantly higher in the CP group than the C group (p < 0.001). SOD and melatonin GCF levels were significantly higher in the control than the GAgP and CP groups (p < 0.05), and significantly lower in the GAgP than the CP group (p < 0.05). The CP group demonstrated a significant negative correlation between GCF-MDA and melatonin concentrations. A positive correlation was observed between SOD and CAL in the CP group and PD in the GAgP group.

CONCLUSIONS

MDA, melatonin and SOD could be considered as biomarkers for oxidative stress in periodontal diseases and might be useful diagnostic aids in distinguishing CP and GAgP patients.

Management and Outcome of Borderline Common Bile Duct with Stones: A Prospective Randomized Study

INTRODUCTION

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.

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Postoperative Outcome after Major Liver Resection in Jaundiced Patients with Proximal Bile Duct Cancer without Preoperative Biliary Drainage

BACKGROUND/AIMS

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.

METHODS

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.

DESIGN

A case-comparison study.

RESULTS

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.

CONCLUSIONS

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.

Comparative Study Between Laparoscopic Heller Myotomy Versus Pneumatic Dilatation for Treatment of Early Achalasia: A Prospective Randomized Study

INTRODUCTION

Achalasia is an incurable primary motor disorder of the esophagus. The best treatment modality for achalasia is still controversial. This study compared the short- and intermediate-term outcome between endoscopic pneumatic dilatation (EPD) versus laparoscopic esophageal myotomy (LEM) for the management of adult patients with early-stage achalasia.

PATIENTS AND METHODS

This was a prospective randomized controlled study of adult patients (20-50 years old) who presented with early-stage achalasia (esophageal diameter of <3.5 cm on contrast esophagography). Patients were classified into two groups according to the method of management: Group A patients were treated with LEM, whereas Group B patients were treated with EPD. Follow-up evaluations were conducted at 1 week, 3 months, 6 months, and then 1 year.

RESULTS

In total, 50 patients were managed for a manometrically confirmed diagnosis of achalasia. The median age of presentation was 31.5 years, with a male-to-female ratio of 0.4:1. Both groups were comparable regarding patient demographics and preoperative severity of the condition. The rate of symptoms relief was 76% in EPD compared with 96% in LEM (P=.04). There was a significant lowering of lower esophageal sphincter in the LEM group (P=.0001). Perforation of the esophagus occurred in 8% of the patients during EPD, whereas mucosal tears occurred in 4% of the patients during LEM. Reflux symptoms developed in 28% and 16% of the patients in the EPD and LEM groups, respectively.

CONCLUSIONS

LEM was more effective clinically and manometrically for patients with early-stage achalasia than EPD. There was no significant difference between the two procedures regarding complications.

Management of post-cholecystectomy biliary fistula according to type of cholecystectomy

BACKGROUND AND STUDY AIMS

A study was undertaken to describe the management of post-cholecystectomy biliary fistula according to the type of cholecystectomy.

PATIENTS AND METHODS

A retrospective analysis of 111 patients was undertaken. They were divided into open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) groups.

RESULTS

Of the 111 patients, 38 (34.2 %) underwent LC and 73 (65.8 %) underwent OC. Endoscopic retrograde cholangiopancreatography (ERCP) diagnosed major bile duct injury (BDI) in 27 patients (38.6 %) in the OC group and in 3 patients (7.9 %) in the LC group (P = 0.001). Endoscopic management was not feasible in 15 patients (13.5 %) because of failed cannulation (n = 3) or complete ligation of the common bile duct (n = 12). Endoscopic therapy stopped leakage in 35 patients (92.1 %) and 58 patients (82.9 %) following LC and OC, respectively, after the exclusion of 3 patients in whom cannulation failed (P = 0 0.150). Major BDI was more commonly detected after OC (P < 0.001). Leakage was controlled endoscopically in 77 patients (98.7 %) with minor BDI and in 16 patients (53.3 %) with major BDI (P < 0.001).

CONCLUSIONS

Major BDI is more common in patients presenting with bile leakage after OC. ERCP is the first-choice treatment for minor BDI. Surgery plays an important role in major BDI. Magnetic resonance cholangiopancreatogrphy (MRCP) should be used before ERCP in patients with bile leakage following OC or converted LC.

Intraoperative endoscopic retrograde cholangio-pancreatography: A useful tool in the hands of the hepatobiliary surgeon

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.

Long term outcomes of choledochoduodenostomy for common bile duct stones in the era of laparoscopy and endoscopy

BACKGROUND/AIMS

Choledochoduodenostomy (CDD) has been reported as an effective treatment of Common bile duct stones (CBDS). This study was designed to analyze short term and long term outcomes of CDD for CBDS.

METHODOLOGY

Demographic data, preoperative, intraoperative and postoperative variables were collected. The long term assessment was done in a prospective manner included clinical examination, liver function, abdominal ultrasound, MRCP, upper GIT endoscopy and assessment of quality of life using Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

A total of 388 consecutive patients underwent CDD, the mean age was 57.92±13.25 years. The mean CBD diameter was 18.22±4.01 mm. The mean operative time was 81.21±20.23 minutes. Two patients had recurrent stone (0.06%) and managed successfully by endoscope. Gastritis was observed in 16.9% patients. No patient developed sump syndrome, deterioration in liver function or cholangiocarcinoma. Total and subgroup scores on the GIQLI before and after CDD differed significantly at follow-up (P=0.0001).

CONCLUSION

CDD is a safe and effective method of drainage of CBD after clearance of CBDS. Long term outcomes are acceptable with good quality of life. Sump syndrome is extremely rare; CDD may be associated with mild to moderate gastritis. CDD doesn't lead to development of cholangiocarcioma.

Challenge and Successful Application for Scale Removal in Oil Field, Egypt: Field Study

Abstract

Water flooding is the hinge pin for Petrobel Oil Field. Water injection is supplied from shallow water supply wells. Compatibility tests, Petrographic Techniques and quantitative calculations of scale tendency using specific software had indicated probable deposition of calcium sulphate scale in the near-wellbore (Critical Matrix). Calcium sulphate scale, paraffin & was have been recognized to be a major operational problem. The bad consequences of scale formation& organic deposits comprised the contribution to flow restriction thus resulting in oil and gas production decrease. The nature of calcium sulphate scale is very hard and can't be dissolved with known dissolver. Sister companies that has similar problem were always going to the mechanical remover options which usually lead to further formation damage when invasion of formation rock by small particle sizes of the scale components.

Extensive lab and field work was conducted to determine the suitable chemicals to dissolve calcium sulphate scale.

The Production of Sidri formation which is currently contained 23 % of belayim land field OOIP (original oil in place) and currently contributes 27 % to the total oil production has been stopped dramatically in some wells.

Sidri formation exhibits a high degree of permeability, heterogeneity and increase water injection was done in some areas that lead to increase the possibility of forming scale, most of scale in Belayim onshore is calcium sulphate.

Precipitation of mixed organic/inorganic deposits (Calcium Sulfate Scale) resulted in decreasing the permeability in the critical matrix and perforation tunnels. Scale formed in the near-wellbore reduces oil production by blocking the narrow pore throats of the matrix itself

This paper highlights Petrobel first application by using the new innovation product SCSR in Belayim land field (Sidri formation), its success and results based on extensive lab studies, SCSR was tested and applied through an effective treatment strategy proposed to remove the scale efficiently; the program was designed taking into consideration the nature of the scale. Furthermore the proposed treatments were conducted and placed using coiled tubing (CT).

Short and long-term results of laparoscopic total fundic wrap (Nissen) or semifundoplication (Toupet) for gastroesophageal reflux disease

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a common upper GIT disorder. The choice of surgical management options is debatable between laparoscopic Nissen fundoplication (LNF) and Toupet fundoplication (LTF) especially in cases with esophageal dysmotility. PATIENTS AND METHODS/AIMS: 102 patients with chronic GERD divided into 2 groups. Group (1): Patients with good peristalsis (n=70) done LNF. Group (2): Patients with poor peristalsis (n=32) patients done LTF to compare the outcome. They were included in this study. They subjected to clinical, radiological and esophageal motility investigations.

RESULTS

In postoperative period, Recurrent of heartburn, dysphagia and abdominal distension were found in 5.71% , 14.28% and 27.14% post LNF and in 9.37%, 15.62% and 15.62% post LTF respectively. Pre operative LESP was 10.16±5.4 mmHg in LNF & 9.56±3.51 mmHg in LTF group increased to 20.7±7.84 mmHg early after LNF (p<0.0001) & 15.26±6.47 early after LTF (p = 0.0002). Esophageal 24hrs pH metry in early and late post operative showed a significant improvement of % reflux (p < 0.001) in both groups.

CONCLUSION

Toupet fundoplication became the procedure of choice of cases with esophageal dysmotility due to its ease of application, patient satisfaction, low dysphagia rate and low levels of abdominal distension.

Outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease in non-responders to proton pump inhibitors

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.

Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study

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.

Mirizzi Syndrome: How it could be a challenge

BACKGROUND/AIMS

Mirizzi syndrome (MS) is a rare complication of cholelithiasis. This entity should be considered in the differential diagnosis of all patients with obstructive jaundice. Failure to recognize this condition preoperatively can result in a major bile duct injury. In this study, our aim is to describe the clinical presentations, investigations, operative details, endoscopic management and the complications of both procedures.

METHODOLOGY

We performed a retrospective analysis on the records of 65 patients with MS. All patients had a cholangiogram; either magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). We used a McSherry classification to divide patients with MS into type I MS and type II MS. Those patients had undergone different types of management either ERCP and/or surgery.

RESULTS

The incidence of MS was 0.98% from a total of 4600 patients who had undergone cholecystectomy. From 65 patients with MS, 20 patients underwent ERCP where it was the sole treatment (18 of which had stent while 2 had the stone extracted). The overall surgically treated patients were 45 (23 patients with preliminary ERCP with stent and 22 patients with primary surgical treatment), 18 patients had MS type I while 27 patients had MS type II. Patients with different types of MS underwent different types of surgical procedures.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience)

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.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

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.

Pancreatic cystic neoplasms: predictors of malignant behavior and management

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.

Laparoscopic Heller myotomy for achalasia: analysis of successes and failures

BACKGROUND/AIMS

The outcome of laparoscopic myotomy for achalasia is dictated by many factors.

METHODOLOGY

A retrospective study was conducted between 1997-2007, 58 patients who fulfilled all criteria for the diagnosis of achalasia underwent laparoscopic Heller myotomy and 45 (77.6%) were included. Mean follow-up period was 36±15 months; 56 patients had Dor fundoplication; 17 patients had been previously treated by pneumatic dilatation. All steps of the procedure, esophageal manometric findings and radiological records were analyzed to determine factors contributing to the clinical success or failure of the operation. The main outcome measure was swallowing status.

RESULTS

Median hospital stay was 3±1 days and mean operative time was 75±20min. There were 7 intra-operative mucosal injuries; all sutured laparoscopically (5 had previous pneumatic dilatation). Good or excellent relief of dysphagia was obtained in 41 patients and was persistent among 2 patients (both had pneumatic dilatation preoperatively). The remaining 2 patients developed gastroesophageal reflux symptoms. These 41 patients had a preoperative smaller diameter of the esophagus (stage I, II and III), while those with guarding results (4) had stages III and IV. There was a decrease in LES pressure from 45±7mmHg to 10±2mmHg without evidence of restoration of esophageal peristalsis in any patient.

CONCLUSIONS

Laparoscopic Heller myotomy with Dor fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. A good postoperative result is expected when the length of myotomy is adequate, LES pressure declines substantially, preoperative esophageal dilation is not excessive and distortion of the distal esophagus is absent.

Angiotensin-converting enzyme (ACE) serum levels and gene polymorphism in Egyptian patients with systemic lupus erythematosus

Objectives: to investigate the association of angiotensin-converting enzyme (ACE) gene polymorphism and serum ACE level among Egyptian SLE patients and its relation to disease activity parameters. Subjects and methods: we enrolled 50 Egyptian female systemic lupus erythematosus (SLE) patients and 29 healthy controls. Measurement of serum ACE level was done using ELISA, and the ACE genotype was determined by polymerase chain reaction using genomic DNA from peripheral blood. Results: a significant difference was found in ACE genotypes between SLE patients and controls (χ2 = 7.84, p = 0.02). The frequency of ACE DD versus (DI and II) genotypes was significantly higher in SLE patients compared with controls (χ2 = 5.57, p = 0.018 and OR for risk of SLE was 3.1 with 95% confidence interval: 1.198.06). Mean serum ACE level was significantly higher in the SLE group compared with controls ( p = 0.006). Subjects with DD genotype had a significantly higher mean level than those with DI ( p = 0.015) and II genotypes ( p = 0.02). Lupus nephritis patients had a significantly higher frequency of DD versus DI and II genotypes compared with lupus patients without nephritis (Fisher's exact test, p = 0.025) and controls (χ 2 =8.74, p = 0.003). SLE patients with vasculopathy had a significantly higher frequency of DD versus DI/II genotypes compared with SLE patients without vasculopathy (Fisher's exact test, p = 0.04) and controls (χ2 = 9.84 and p = 0.002). Mean serum ACE level was significantly higher in the lupus nephritis and SLE patients with vasculopathy compared with controls ( p = 0.008, p = 0.001, respectively). Significant positive correlations were found between serum ACE level and serum creatinine and 24 h proteinuria ( p = 0.03, 0.009, respectively). SLE patients with DD genotype had a statistically significant higher mean SLEDAI score than those with (DI/II) genotypes ( p = 0.02). Significant positive correlation was found between serum ACE levels and SLEDAI scores ( p = 0.04). Conclusion: ACE genotype and subsequently serum ACE level could be associated with the disease activity of Egyptian SLE patients; in addition, ACE deletion polymorphism might be used as one of the predictive factors for the activity of SLE. Further studies on a larger number of patients should be done to determine the exact prevalence of ACE gene polymorphism among Egyptian SLE patients.

Post-cholecystectomy biliary injuries: one center experience

BACKGROUND/AIMS

Post-cholecystectomy bile duct injuries (BDIs) represent a challenge in diagnosis and management.

METHODOLOGY

From March 1995 to August 2009, 274 patients with post-cholecystectomy BDIs were managed at our center. All patients were subjected to laboratory tests, sonography, ERCP and MRCP. The management varied according to the type of injury.

RESULTS

Seventy-one (25.9%) LC and 203 (74.1%) OC were performed; 8(2.9%) were detected intraoperatively; 270 patients were referred from other hospitals. From those discovered intraoperatively, 7 had hepatico-jejunostomy and one died from severe peritonitis; 11 (4%) presented with generalized and 112 (40.9%) with localized peritonitis. The leak site was the cystic duct (57 cases), accessory duct in the liver bed (5 cases), right hepatic duct (4 cases) and lateral tear in the CBD (12 cases). Endoscopic stenting was performed for all of them. The remaining 34 patients had a completely ligated distal duct and therefore had hepatico-jejunostomy Roux loop; 143 patients (52.2%) presented with early (79 cases) and late (64 cases) jaundice; 126 cases had hepatico-jejunostomy. The remaining 17 patients were treated by balloon dilatation.

CONCLUSIONS

Endoscopic stenting can manage cases with cystic or accessory duct leak while, hepatico-jejunostomy Roux loop represents the golden procedure for management of transected or ligated CBD.

Surgical management of gastric gastrointestinal stromal tumor: a single center experience

BACKGROUND/AIM

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Our objective is to evaluate the outcome of surgical treatment of primary gastric GIST.

MATERIALS AND METHODS

Between January 1997 and April 2008, thirty seven consecutive patients underwent resection for GISTs (35 patients with primary gastric GISTs and two patients with intestinal GISTs who were excluded from the study). These patients underwent upper endoscopy ± biopsy, barium meal and abdominal CT scan. Patients' demographics and clinical presentations were analyzed. Perioperative parameters measured included operative times, estimated blood loss, intraoperative finding, surgical techniques, morbidity and length of hospitalization. Recurrence and survival were also analyzed.

RESULTS

Of the 35 patients with gastric GISTs included in the study, 63% were female. The median age was 59 ± 14 years (range, 23 to 75 years). The primary presenting symptoms were bleeding and dyspepsia; 43% of these tumors were located mainly in the body of the stomach. Tumor size was < 10 cm in 80% of the patients. The average tumor size was 6.3 ± 3.2 cm (range from 3 to 13 cm). Regarding the surgical management, 20 patients (57%) underwent gastric wedge resection, eight patients (23%) underwent partial gastrectomy and the remaining seven patients (20%) underwent total gastrectomy. Radical resections were found in 32 patients (91.5%) while palliative resections were found in three patients (8.5%). The resected lymph nodes were negative in 32 patients (91.5%). Recurrence was noted in three patients, with a median time to recurrence of 14.3 months (range, 7 to 28 months). The three- and five-years survival in patients who underwent wedge resection was 92% and 81%, respectively, where it was 95% and 87%, respectively, in patients who underwent gastrectomy (either partial or total). There were no major intraoperative complications or mortalities.

CONCLUSION

Complete surgical resection either through wedge resection or gastrectomy with negative margins remains the gold standard treatment in the management of patients with primary resectable gastric GISTs.

Long-term outcomes of laparoscopic antireflux surgery

BACKGROUND/AIMS

The short-term outcomes of laparoscopic antireflux surgery (LARS) in treatment of gastroesophageal reflux disease (GERD) are quite good, but some long-term studies have shown that the early good results are worsening with time.The aim of this study was to evaluate retrospectively, the long-term outcome of LARS with special attention to determinant factors.

METHODOLOGY

From August 1994 (start of Mansoura program) to June 2004, 250 patients underwent LARS at the Mansoura gastroenterology surgical center, Mansoura University, Egypt. Preoperative symptoms and the results of esophageal functional studies as well as details of the operation and follow-up were recorded in a database. In 2009, 180 out of these 250 patients (72%) were contacted and reassessed with regard to their clinical outcome and patient satisfaction. There were no differences in presentation profiles of those patients contacted and those could not.

RESULTS

At a median follow-up of 70 months, individual symptoms, among those who had them preoperatively, were as follows: heartburn (175 patients) improved in 160 (91.4%) and resolved in 130 (74.3%), regurgitation (115) improved in 106 (92.2%) and resolved 93 (80.9%), dysphagia (65) improved in 45 (69.2%) and resolved in 37 (56.9%), cough (18) improved in 12 (66.7%) and resolved in 8 (44.4%), and hoarseness (10) improved in 7 (70%) and resolved in 4 (40%). Patient satisfaction was better among younger males with preoperative typical reflux symptoms (heartburn without dysphagia), respondents to medication and those had short floppy complete (Nissen) wrap (p < 0.05). Five patients (2.8%) developed a new onset of dysphagia, 16 patients (8.9%) developed new or increased diarrhea and 18 patients (10%) developed bloating postoperatively. Seventy patients (38.9%) were taking some form of antacid medication (20% prescripted and 18.9% nonprescripted) and 6 (3.3%) had undergone reoperation (2 for tight wrap and 4 for disrupted herniated wrap).

CONCLUSION

LARS provides effective long-term relief of GERD, however one-fifth of patients needs regular antacid medication. Younger males, typical reflux symptoms (heartburn without dysphagia) and preoperative response to medication are predictors of superior outcomes. Short floppy complete wrap is more durable than an incomplete one.

Prognostic factors affecting survival and recurrence after hepatic resection for hepatocellular carcinoma in cirrhotic liver

AIM

Hepatic resections for hepatocellular carcinoma (HCC) in cirrhotic liver are characterized by early recurrence and poor survival. In this study, we analyzed several factors affecting both survival and recurrence after hepatic resection.

PATIENTS AND METHODS

From October 1995 to April 2007, 550 patients underwent hepatic resections, of which, 175 patients had HCC in cirrhotic liver in Gastroenterology Surgical Center, Mansoura University, Egypt. There were 131 males (74.9%) and 44 females (25.1%) with a mean age of 54.8 +/- 9.2 years (ranges from 26 to 75 years).

RESULTS

Most of our patients were in Child's Pugh class A (86.9%). Major hepatic resection was done for 65 patients (37.1%), segmentectomy was done for 62 patients (35.4%), and localized resection was done for 48 patients (27.4%). Hospital mortality occurred in 16 (9.1%) patients, while hospital morbidity occurred in 40% of patients. The 1, 3, and 5 years survival were 68.6%, 29.6%, and 10.7%, respectively. The prognostic factors affecting recurrence were multifactorial, and the univariate analysis showed that multifocality of the tumor (p = 0.006), capsule (p = 0.001), staging (p = 0.001), blood transfusion (p = 0.02), infiltration of the cut margin (p = 0.001), vascular invasion (p = 0.006), and lymph nodes infiltration (p = 0.014) affect the recurrence rate, while with multivariate analysis, only cut margin was significantly affecting the recurrence (p = 0.026). Also, factors that significantly predicted survival were preoperative serum albumin (p = 0.005), tumor differentiation (p = 0.008), staging (p = 0.001), tumor's capsule (p = 0.001), cut margin (p = 0.031), vascular invasion (p = 0.049), and operative blood transfusion (p = 0.001). However, tumor differentiation (p = 0.048) was the only independent factor on multivariate analysis affecting long-term survival.

CONCLUSION

In our experience, the prognostic factors after resection for recurrence and survival are different and multifactorial. However, resection of HCC in cirrhotic liver with preserved liver function is the treatment of choice in the present time and can be done with favorable results.

Endoscopic management of postoperative bile duct injuries: a single center experience

BACKGROUND/AIM

Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI.

MATERIALS AND METHODS

Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared.

RESULTS

The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%).

CONCLUSIONS

Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.

Response of atypical symptoms of GERD to antireflux surgery

BACKGROUND/AIMS

The results of laparoscopic Nissen's fundoplication (LNF) were compared in patients having typical and atypical symptoms of Gastroesophageal reflux disease (GERD). Atypical symptoms include asthma, chronic cough, non-cardiac chest pain, and ear, nose, and throat symptoms. The effectiveness of antireflux surgery in relief of these symptoms is uncertain.

METHODOLOGY

100 patients with GERD underwent laparoscopic Nissen's fundoplication in El-Mansoura Gastro-enterology center between January, 2002 and March, 2004. Patients were classified according to preoperative symptoms into 3 groups; group 1 (71 cases with severe typical and minimal atypical symptoms), group 2 (18 cases with severe typical and severe atypical symptoms) and group 3 (11 cases with minimal typical and severe atypical symptoms). Patients were reassessed within a mean period of 24 +/- 12 months after surgery.

RESULTS

Duration of illness was nearly similar in the three groups (3.2 +/- 2.7:3.3 +/- 2.9:3.7 +/- 3.2 years). In group 1, typical symptoms improved in 66 (92.9%) cases and resolved in 63 (88.7%). In group 2, typical symptoms improved in 17 (94.4%) and resolved in 16 (88.9%), whereas atypical symptoms improved in 15 (83.3%) and resolved in 10 (55.6%). In group 3, atypical symptoms improved in 9 (81.8%) and resolved in 5 (45.5%). Endoscopic, radiologic, esophageal motility and pH metry studies were nearly similar in the 3 groups.

CONCLUSIONS

Antireflux surgery improves atypical symptoms of GERD, but symptom resolution occurs in less than half of cases.

216 cases of pancreaticoduodenectomy: risk factors for postoperative complications

BACKGROUND/AIMS

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequlae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux (DGER) to endoscopic severity in patients with GERD and Barrett's esophagus.

METHODS

Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to non-erosive reflux disease (NERD), erosive reflux disease (ERD) and Barrett's esophagus (BE). Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were done to all patients.

RESULTS

Seventy one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed that 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux only, 18 (19.8%) had bile reflux only and 18 patients (19.8%) had no evidence of abnormal reflux. The percentage of the total time of bilirubin absorbance above 0.14, in 71 patients with ERD was (8.18 +/- 11.28%), and in 9 patients with BE was (15.48 +/- 30.48%) which was significantly greater than that in 11 patients with NERD (4.48 +/- 8.99%), p < 0.05 and p = 0.01 respectively. All BE patients had abnormal esophageal bile reflux (3 bile alone and 6 mixed bile and acid); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (13 bile alone and 31 mixed bile and acid); meanwhile 15 of them (21.2%) had abnormal acid exposure alone. Of the 11 patients with NERD, 4 patients (36.4%) had abnormal esophageal bile reflux, 2 of them mixed with acid.

CONCLUSIONS

The Bilitec method reliably identifies the presence of bilirubin and quantitatively detects duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in GERD patients in this study. Bile reflux either alone or mixed with acid reflux contributes to the severity of erosive and non-erosive reflux disease as well as to Barrett's esophagus.

Quality of life and patient satisfaction 3 months and 3 years after laparoscopic Nissen's fundoplication

BACKGROUND/AIM

This study is based on studying the quality of life and degree of satisfaction among gastroesophageal reflux disease (GERD) patients after Laparoscopic Nissen's fundoplication (LNF) operations.

SUMMARY BACKGROUND DATA

A GERD patient is most interested in symptom relief, whereas his surgeon will also be interested in the improvement of anatomical and functional investigations.

MATERIALS AND METHODS

One hundred patients with symptoms of GERD, adequate motility study and positive 24-hour pH studies underwent LNF in El-Mansoura Gastroenterology Center between 2002 and 2004. All patients completed the Gastroesophageal Reflux Disease-Health Related Quality Of Life (GERD-HRQL) questionnaire both pre- and postoperatively (early within 3 months after operation and late after 3 years). Furthermore, all patients were given a form with 4 grades (excellent, good, fair and poor) and they were requested to freely assess both the early and late clinical outcomes.

RESULTS

There was statistically significant improvement in all the items of the GERD-HRQL questionnaire, both early and late (P < 0.001). With regard to patient satisfaction; only 58 cases showed excellent clinical satisfaction early postoperatively, while 29, 8 and 5 patients showed good, fair and poor responses, respectively. These figures improved on late followup (P < 0.05), i.e., 76 excellent, 16 good and 8 fair results.

CONCLUSIONS

LNF improves all the items of quality of life among GERD patients significantly (P < 0.001). Patient satisfaction after LNF improves with time; 58 cases showed early postoperative excellent clinical satisfaction as compared to 76 late cases (P < 0.05). However, LNF may not be the standard management of reflux symptoms, particularly from some patients' perspective.

Bile reflux measurement and its contribution to the severity of reflux esophagitis

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequelae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux to endoscopic severity in patients with GERD and Barrett's esophagus (BE).

MATERIALS AND METHODS

Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to nonerosive reflux disease (NERD), erosive reflux disease (ERD) and BE. Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were performed in all patients.

RESULTS

Seventy-one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE, which were suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed the following: 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux alone, 18 (19.8%) had bile reflux alone and 18 patients (19.8%) showed no evidences of abnormal reflux. The percentage of the total time of the bilirubin absorbance > 0.14 in 71 patients with ERD was (8.18+/-11.28%) and in 9 patients with BE was (15.48+/-30.48%), which was significantly greater than that in 11 patients with NERD (4.48+/-8.99%), P<0.05 and P=0.01 respectively. All the BE patients had abnormal esophageal bile reflux (bile alone (3 patients)); and mixed bile and acid (6 patients)); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (alone (13 patients) and mixed bile and acid (31 patients)); meanwhile, 15 of them (21.2%) had abnormal acid exposure alone. Despite 11 patients having NERD, four patients (36.4%) had abnormal esophageal bile reflux and two of them had mixed reflux of bile with acid.

CONCLUSION

We believe that the Bilitec method reliably identifies the presence of bilirubin and quantitatively detects the duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in our GERD patients. Bile reflux either alone or along with acid reflux contributes to the severity of erosive and nonerosive reflux diseases as well as in BE.

Short gastric vessels division in Laparoscopic Nissen Fundoplication

BACKGROUND/AIMS

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Partial posterior wrap (toupet)in patients with defective esophageal body motility

BACKGROUND

The effectiveness of partial posterior wrap (Toupet procedure) in patients with defective esophageal body motility is controversial.

AIM OF THE STUDY

To evaluate the effect of Toupet procedure upon the outcome of laparoscopic (LF) and open (OF) fundoplications in gastroesophageal reflux disease (GERD) patients with defective esophageal body motility.

PATIENTS AND METHODS

This study included 32 patients with severe GERD who underwent Toupet procedure; 18 (56.25%) OF 'and 14 (43.75%) LF. Outcome measures included assessment of relief of the symptoms, results of repeated endoscopy, barium study, manometry and pH metry; both early (within six months) and late (two years at least).

RESULTS

Relief of heartburn was achieved in 26 patients (81.3%). These include 14 (77.7%) and 12 (85.7%) patients who underwent OF and LF respectively. Occasional dysphagia developed in six patients (18.7%) early, and three (9.4%) late; all were managed conservatively. Endoscopic esophagitis healed in 26 patients (81.3%); 14 (77.7%) OF and 12 (85.7%) LF. Mean LES and body pressures improved (10.5 to 17.7 and 29.0 to 41.0 mmHg respectively). Persistent acid reflux was detected in six patients (18.7%); two (22.3%) OF and two (14.3%) LF.

CONCLUSION

Toupet fundoplication is an effective procedure for reflux control except in patients with severe GERD.

Effect of monophasic blood flow on the patency of microvascular anastomoses

The effect of monophasic blood flow on the patency of microvascular anastomoses in the rat femoral artery was evaluated by the authors. An experimental model of monophasic blood flow was created in the rat femoral artery to simulate that seen in patients with peripheral vascular disease. Microvascular anastomoses were performed, and the patency at the first hour and 24 hr later was determined. The studies demonstrated that microarterial anastomotic patency was the same when performed in vessels with monophasic or triphasic flow patterns. The authors conclude that monophasic blood flow is not an absolute contraindication for free-tissue transfer.

Cerebral atrophy: a schistosomiasis manifestation?

Preliminary studies with sonography indicated that a reduced brain mantle index and dilated ventricles were frequently seen in patients with chronic Schistosoma mansoni infection. Computerized tomography (CT) was used to confirm our earlier observations and to obtain more accurate measures. Brain scans of 25 patients with chronic S. mansoni infection showed mild to moderate degrees of cortical atrophy in 9 cases (36%) and central atrophy in 3 (12%). The remaining 16 subjects and 10 controls showed normal brain scans. The present study is the first report documented by CT showing a significant correlation between chronic S. mansoni infection and cerebral atrophy.