Endovascular tibial arteries revascularization and its outcome on wound healing with split-thickness skin grafts for limb salvage in patients with below-the-knee vascular disease Ahmed K Allam, Ahmed E.A Moamen, Gamal I El-Habbaa The Egyptian Journal of Surgery 2019 38(4):627-637 Background Continuous and rapid advancement in percutaneous endovascular therapy has led to a significant increase in its use as a primary option for revascularization replacing surgical bypass, and it has become a standard treatment for critical limb ischemia (CLI). Clinical success of percutaneous revascularization has been mostly judged by patency rate and limb salvage, but there is paucity of reports on the outcomes of the wound. We present a retrospective study of immediate angiographic and 6-month clinical outcome of patients who underwent endovascular recanalization of tibial arteries for CLI followed by surgical debridement and wound reconstruction with split-thickness skin graft (STSG) for patients with grade 2 ulcer according to the Wound, Ischemia, foot Infection score. Patients and methods Between January 2016 and April 2017, 47 consecutive adult patients with CLI who underwent endovascular recanalization of infra-popliteal arteries due to more than 50% stenosis or chronic total occlusion with grade 2 chronic wound that was reconstructed using STSG and who had a clinical follow-up of at least 6 months were selected for analysis. Results Forty-seven patients underwent endovascular reconstruction. Forty (85.1%) patients underwent only balloon angioplasty and remaining seven (14.9%) underwent additional bailout stenting for proximal tibioperoneal or anterior tibial arteries. Twenty-eight (59.6%) patients had multiple vessel recanalization, while 19 (40.4%) patients had single vessel recanalization. Linear flow to the foot was achieved in at least one artery, mostly the anterior tibial artery in 32 (68.1%) patients postrevascularization. Successful wound healing occurred in 37 (80.4%) patients, 24 (64.9%) of them underwent wound covering with STSG with graft uptake in 20 (83.3%) patients. Limb salvage was achieved in 41 (89.1%) patients at a 6-month follow-up. Conclusion Endovascular recanalization of tibial arteries is an effective procedure for the treatment of CLI. STSG can be considered a reliable option for achieving wound healing in diabetic foot patients after successful revascularization and proper wound debridement. Normal outflow with at least one of the three infra-popliteal vessels being patent is essential for adequate healing and graft taking.

Modified technique for Kasai porto-enterostomy in biliary atresia and its impact on clinical outcome Ahmed Sallam, Sherif Saleh, Mohamed Taha The Egyptian Journal of Surgery 2019 38(4):638-642 Background Traditionally, the principle of the Kasai procedure is to remove the atretic extrahepatic ducts so as to establish bile flow to the intestine at an early stage and prevent further progression of the disease. Here, we describe modifications to the procedure via a wider and deeper dissection. Aim To assess the new modified technique over the traditional technique used for type III biliary atresia and its impact on the clinical outcome. Patients and methods This is a retrospective study that assessed the outcome of 66 patients who underwent Kasai portoenterostomy (KPE) at Hepatobiliary and Pancreatic Surgery Department, National Liver Institute, Menoufia University between July 2014 and December 2017. The patients were divided into two groups and the outcome after the modified KPE were compared with the traditional KPE regarding clinical outcome and overall survival. Results In all, 66 patients were identified. Of these, 32 were in the traditional KPE group and 34 in the modified KPE group. The modified technique had better short-term clinical outcome than the traditional technique group at 3 and 6 month postoperatively with statistical significance (P=0.006 and 0.017, respectively). The rate of native liver survival was 68.8 versus 31.5% and overall survival was 88.2 versus 65.6%. Conclusion Deep and long incision in fibrous remnant and meticulous anastomosis was associated with favorable outcomes.

Esthetic outcomes of using latissimus dorsi flap for breast reconstruction after breast-conserving surgery Mahmoud Abdelbaky Mahmoud, Mohamed A Amin Saleh The Egyptian Journal of Surgery 2019 38(4):643-655 Background Lesion location and the volume of breast excised in correlation to the total breast volume are cornerstone issues in oncoplastic surgery after surgical breast-conserving surgery affecting the esthetic management plan and protocol implemented. Aim of the study Verifying the value of using latissimus dorsi (LD) myocutaneous flaps in secondary breast reconstruction after surgical breast conservation. Patients and methods A total of 73 cases that have undergone unilateral surgical breast conservation and postoperative radiotherapy, subsequently followed by secondary reconstruction of the breast using the latissmus dorsi as a myocutaneous flap at Ain Shams University Hospital and Bahya Hospital of Breast Cancer between January 2015 and January 2018. Results Binary logistic regression statistical analysis have shown that preoperative overall esthetic score was the only significant predictor of having postoperative excellent/very good esthetic score (P<0.005). Neither age, BMI, location of the tumor, nor duration between surgical breast conservation and LD myocutaneous flap was statistically significantly correlated with postoperative esthetic outcomes. Conclusion The current research study verifies the usefulness of LD flap in the restoration of adequate esthetic outcomes required after surgical conservative manner of breast tumor removal; however racial, ethnic, and anatomical differences should be considered in future research

Efficacy of mastectomy flap fixation in minimizing seroma formation after breast cancer surgery Ahmed S Arafa, Fady Fayek, Joseph RizkI Awad The Egyptian Journal of Surgery 2019 38(4):656-661 Background Seroma formation is considered the most frequent postoperative complication after breast cancer surgery. Serous fluid is collected just under the skin flaps or in the axillary pace immediately following mastectomy preventing adherence of the flaps to the underlying fascia and muscles leading to delay wound healing, infected wound due to repeated aspiration, wound dehiscence, prolonged hospital stay, delay of adjuvant treatment, and finally generating additional costs. Patients and methods A randomized, controlled study was carried out among 138 female patients, who were candidates for mastectomy and axillary clearance. A control group without quilting (69 patients) had a traditional wound closure and the intervention (quilted) group (69 patients) had a sutured flap fixation. Results There were significant differences regarding seroma formation between both groups since it was detected in 22 (31.9%) of the 69 in the suture group and in 39 (56.5%) of 69 in the control group (P<0.004). There were significant differences between means of the number of seroma aspirations among patients with seroma (n=61) by study groups being significantly reduced in in the quilting group (4.3%) versus (18.8%) in the nonquilting group in comparison to the nonquilting group with P value less than 0.008. The range of operative time was 146 (80–160) in the quilting group and 100 (70–135) in the control group. Conclusion Quilting sutures postmastectomy is the most advised technique to minimize seroma formation and its complications. Hence, we recommend quilting of flaps as a routine step at the end of any mastectomy.

A prospective study for superior medial technique as an oncoplastic procedure for lower and outer quadrant breast cancer: oncological safety and clinical outcomes Mahmoud Abdelbaky Mahmoud, Samy Gamil, Hany Rafik The Egyptian Journal of Surgery 2019 38(4):662-673 Background Breast cancer is the most common site of cancer in women in Egypt as it accounts for ∼38.8% of total malignancies among Egyptian women; it is an important cause of mortality among women. For many women with early-stage breast cancer, a combination of partial mastectomy and radiation therapy − together referred to as breast-conserving therapy − is preferable to total mastectomy. Objective To focus on superior medial technique as an oncoplastic procedure for the management of breast cancer and to assess the technique clinically regarding oncological safety, surgical outcomes, and patient satisfaction. Patients and methods It was a prospective, analytical study that included 20 patients aiming to assess clinically the superior medial oncoplastic technique for lower and outer quadrant breast cancer regarding oncological safety and patient satisfaction. This study was conducted at Bahya Specialized Breast Cancer Hospital and Ain Shams University Hospitals. Results All the 20 patients underwent oncoplastic breast surgery which implied two major technical steps, excision of the tumor with a wide safety margin through a predesigned incision with frozen section examination for margins along with formal axillary dissection, followed by immediate reconstruction using superior medial technique. Breast cancer, like other cancers, occurs because of an interaction between an environmental (external) factor and a genetically susceptible host. Normal cells divide as many times as needed and stop. They attach to other cells and stay in place in tissues. Cells become cancerous when they lose their ability to stop dividing, to attach to other cells, to stay where they belong, and to die at the proper time. Conclusion This approach has enabled us to increase the number and extend the indications of breast-conserving surgery with wider margins offering safer oncologic control with more satisfactory cosmetic outcome.

Laparoscopic preperitoneal ventral hernia repair with prolene mesh with fixation through transabdominal prolene stitches Mohamed S Ghali, Mahmoud Abdelbaky Mahmoud, Samy Gamil The Egyptian Journal of Surgery 2019 38(4):674-678 Objective To evaluate the efficacy and safety of our technique in laparoscopic repair of ventral hernias. Summary background data Laparoscopic ventral hernia repair (LVHR) was first reported in 1993. The successful application of laparoscopic techniques for the repair of ventral hernias has been well accepted. The recurrence rate after standard repair of ventral hernias may be as high as 10%, and the wide surgical dissection required often results in wound complications. Use of a laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair. Patients and methods Data on all patients who underwent LVHR performed using our procedure between February 2013 and February 2015 were collected retrospectively. Results LVHR was completed in 27 of the 30 patients (nine men and 21 women) in whom it was attempted. The patients’ mean BMI was 36.5; the mean defect size was 3.2 cm. Mesh averaging 6.3 cm was used in all cases. Mean operating time was 105 min, and hospital stay averaged 1.9 days. Our complication rates were 16.6%. The most common complications were ileus (6.6%) and prolonged seroma (6.6%). During a mean follow-up time of 12 months, the hernia recurrence rate was 3.3%. Overall, 10% of patients had pain for 1 month. Recurrence was associated with vigorous exercise within the first 3 months postoperatively. Conclusion In this series, the preperitoneal laparoscopic technique for ventral hernia repair had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence avoiding the potential complications related to intraabdominal mesh position.

Validation of revised trauma score in the emergency department of Kasr Al Ainy Doaa A Mansour, Hisham A Abou Eisha, Amgad E Asaad The Egyptian Journal of Surgery 2019 38(4):679-684 Background High-flow trauma centers face a huge variety of injury patterns and severity warranting an objective measure to reflect injury severity and consequently the intensity of care required in a resource-limited environment. The revised trauma score (RTS) is a physiological triage system based upon Glasgow coma scale, systolic blood pressure, and respiratory rate that can be used as a prognostic tool in trauma patients. Patients and methods During the initial assessment of 200 blunt trauma victims presenting to Kasr Al Ainy emergency department between October 2015 and February 2016, the RTS was calculated and correlated with injury severity, discharge from the emergency room after initial assessment, ICU admission, length of hospital stay, and mortality. A cut-off RTS was thought to guide the decision-making process and anticipation of the required resources. Results An overall 78.5% of male individuals and 21.5% of female individuals with a mean age of 31.2 years with blunt abdominal trauma presented with a mean RTS of 11.41. No patient with an RTS of 10 or less could be discharged home from the emergency department. There was a statistically significant correlation between RTS and ICU admission and mortality (P<0.001 for both). A cut-off RTS of less than 11 (RTS=10 or less) predicts mortality with a sensitivity of 92.9% and specificity of 81.8%, with area under the curve=0.929. Correlation between RTS and length of hospital stay did not reveal statistical significance (P=0.310). Conclusion RTS can support the discharge decision process and reflect injury severity by predicting the need for ICU and mortality.

Endoscopic preaponeurotic mesh placement in cases of divarication of recti associated or not with midline hernia Hazem Nour, Hatem Mohammad, Mohamed I Farid The Egyptian Journal of Surgery 2019 38(4):685-690 Background Divarication of rectus abdominis muscle is common especially after childbirth. Usually it is asymptomatic but may be associated with backache. Its problem is mainly esthetic and managed by plastic surgeons. General surgeons are called for management of divarication if associated with hernia defects. Till now, there is no unique procedure for the optimal management of divarication of recti associated with midline hernia defects. Open surgical repair, subcutaneous endoscopic repair, and transabdominal laparoscopic repair all with or without mesh fixation could be an accepted solution. Aim of the study The aim of this study is to evaluate the subcutaneous endoscopic plication of the divarication of rectus abdominis muscle, repair of the hernia defect if present, and placement of preaponeurotic nonabsorbable mesh. Patients and methods The study is a prospective clinical trial carried out in Zagazig university hospitals in the period between March 2018 and October 2018, where endoscopic placement of nonabsorbable prolene mesh on the anterior rectus sheath after plication and repair of the defect in cases of divarication of rectus abdominis muscles associated or not with midline hernia was done. Results A total of 19 patients underwent endoscopic plication of rectus abdominis muscle; 12 of them had midline hernia, in whom repair of the defect was done, and the nonabsorbable mesh was placed over the anterior rectus sheath, with good outcome comparable to most studies on that topic, apart from seroma, which occurred in five cases, and prolonged operative time. Conclusion Preaponeurotic endoscopic technique for plication of divarication of rectus abdominis muscle and onlay mesh placement is better than open surgical management. It is a safe, reproducible, and effective alternative for patients with ventral hernias associated with divarication of rectus abdominis muscle.

Post-right hemicolectomy ileostomy and mucous fistula through single skin opening: comparative study with ileostomy and mucous fistula through two skin openings Mahmoud Farghaly, Tarek Youssef The Egyptian Journal of Surgery 2019 38(4):691-699 Background Right Hemicolectomy (RHC) is a common procedure for various right-sided colon pathologies; cancer colon or terminal ileum, perforated appendix with unhealthy cecal base, traumatic injuries and other less commonly indications. Ileo-colic anastomosis is the preferred next step following resection of the diseased segment, however, in certain situations, ileostomy (IL) and mucus fistula (MF) may be done due to excessive soiling or post-leakage of ileo-colic an astomosis or due to bad general condition of patient at this situation. Analternative approach can be done in such cases, which is the construction of aside-to side ileo-colic anastomosis which is then brought out in the right abdominal wall anastoma, so that reconstruction can be done with out midline laparotomy. Here, in our study we did a short term comparison between two groups of patients underwent ileosto my with mucousfistula.The first under went posterior wall anastomosis and the second without. Aim of Study Compare between Two groups of patients post RHC; one underwent IL&MF through single skin opening with posterior wall anastomosis and the other one did IL&MF through separate skin openings, regarding postoperative and restoration of continuity outcomes. Patients and Methods This is a retrospective cohort study. Data retrieved from the medical records of Ain Shams University Surgery Hospital medical records. Patients were divided into 2 groups according to the type of ileostomy and mucus fistula; Group A: underwent ileostomy and mucusfistula with posterior wall anastomosis. Group B: operated up on by ileostomy and mucus fistula without posterior wall anastomosis. Results Twenty-three patients underwent ileostomy and mucus fistula through single skin opening with posterior wall anastomosis, while 25 patients were through 2 skin openings without posterior wall anastomosis. No statistically significant difference between both groups regarding postoperative stoma-related complications. Restoration of continuity showed significantly more rate of wound infection in-case of ileostomy and mucus fistula through separate skin openings that’s attributed to midline laparotomy. Conclusion Ileostomy and mucus fistula through single skin opening with posterior wall anastomosis, is associated with similar complications rate to separate skin openings ileostomy and mucus fistula, however, its less risk of wound related SSI along with its ramifications as wound dehiscence and incisional hernia, due to avoidance of midline laparotomy when restoring bowel continuity is a worthy advantage.

Arterioarterial prosthetic loop: a new approach for hemodialysis access as an unusual vascular access Islam Atta, Ahmed Sawaby, Amr El Abd The Egyptian Journal of Surgery 2019 38(4):700-706 Background Vascular access has always been the Achilles repair of hemodialysis. Developments in health care have carried forward patients requiring management who have no veins appropriate for formation of arteriovenous fistula or insert of central venous catheters. This study reports arterioarterial prosthetic loop (AAPL) graft as an effective access for hemodialysis patients with venous occlusion. Objective To assess AAPL graft regarding primary and secondary patency rates and incidence of complications. Patients and methods This study was performed on 20 patients with the end-stage renal diseases. The age of the patients ranged between 47 and 72 years, with a mean age of 57.9 years. Results The primary patency rates were 100, 100, 95, 90, and 80%, respectively, and the secondary patency rates were 100, 100, 100, 95.0, and 95.0% at 1, 3, 6, 9, and 12 months, respectively. Conclusion AAPL can offer an efficient access for hemodialysis in such special group of patients with unsuitable arteriovenous access or having cardiac insufficiency.