Resistant corneal ulcers in a tertiary care ophthalmic center in Egypt: 10 years epidemiological study

AIM:To investigate the magnitude of problem caused by resistant corneal ulcers and its epidemiological characteristics.METHODS:Patients with corneal lesions were selected and carefully examined and cases with resistant corneal ulcers were further investigated and data were recorded using a specific data sheet designed in hospital.Then,collected data from patients were statistically analyzed.RESULTS:Totally 1939 cases were included in the study,including 816 fungal cases(42.1%)and 1123(57.9%)non-fungal cases.Age of the participants ranged from 18 to 73y.Fungal cases were more common in middle age(35-55y).Men were more affected(53.5%)of cases included in the study.Keratomycosis affected more unskilled personnel(75.1%),large families with small houses(higher crowding index 73.9%),rural(64.5%)residence.Patients with sanitary water sources(34.8%)and waste disposal(24.4%)were less affected.CONCLUSION:Keratomycosis is more frequent in unskilled personnel,rural locations,outdoor water sources and insanitary waste disposal systems.Corneal trauma and contact lens are common risk factors.

Urachal Cancer: Experience of a High-Volume Bladder Cancer Center

Introduction: Primary urachal cancer (UrCa) is rare, with an estimated incidence of 0.2% - 0.5% of all bladder tumors. Although the preferred treatment is surgical, there is no consensus on the best approach. We present our experience managing 14 cases of primary UrCa. Methods: A retrospective analysis was conducted on the clinical records of a high-volume bladder cancer center in the UK to identify patients diagnosed with UrCa between May 2013 and June 2022. Results: 9 males and 6 females, aged between 30 and 85 years, were included. The diagnosis was most commonly made via flexible cystoscopy and CT for haematuria. 3 patients had metastasis at presentation, and while radiologically no patients showed positive lymph nodes, 2 patients were found to have positive lymph nodes on histopathology. 13 patients underwent partial cystectomy, with 1 undergoing radical cystoprostatectomy. 8 patients underwent concurrent umbilectomy and/or lymphadenectomy. The most common histological subtype was mucinous adenocarcinoma. 2 patients experienced local recurrence and underwent transurethral resection, while 6 patients experienced metastasis. Metastasis-free survival rate was 74.1% and 55.6% at 12 and 24 months, respectively. Umbilectomy and lymphadenectomy did not decrease rates of positive surgical margin, local recurrence, metastasis, or mortality. Conclusions: UrCa is a rare and aggressive malignancy that can occur at any age and may be advanced upon presentation. Bladder-sparing surgery is becoming more prevalent, with chemotherapy being reserved for recurrence or metastasis. In our series, routine umbilectomy and lymphadenectomy did not improve oncologic outcomes. However, lymphadenectomy may have a role in cancer staging.

Renal calcification in children with renal tubular acidosis:What a paediatrician should know

Renal tubular acidosis(RTA)can lead to renal calcification in children,which can cause various complications and impair renal function.This review provides pediatricians with a comprehensive understanding of the relationship between RTA and renal calcification,highlighting essential aspects for clinical manage-ment.The article analyzed relevant studies to explore the prevalence,risk factors,underlying mechanisms,and clinical implications of renal calcification in children with RTA.Results show that distal RTA(type 1)is particularly associated with nephrocalcinosis,which presents a higher risk of renal calcification.However,there are limitations to the existing literature,including a small number of studies,heterogeneity in methodologies,and potential publication bias.Longitudinal data and control groups are also lacking,which limits our understanding of longterm outcomes and optimal management strategies for children with RTA and renal calcification.Pediatricians play a crucial role in the early diagnosis and management of RTA to mitigate the risk of renal calcification and associated complications.In addition,alkaline therapy remains a cornerstone in the treatment of RTA,aimed at correcting the acid-base imbalance and reducing the formation of kidney stones.Therefore,early diagnosis and appropriate therapeutic interventions are paramount in preventing and managing renal calcification to preserve renal function and improve long-term outcomes for affected children.Further research with larger sample sizes and rigorous methodologies is needed to optimize the clinical approach to renal calcification in the context of RTA in the pediatric population.

Argon laser photocoagulation versus intrastromal voriconazole injection in treatment of mycotic keratitis

AIM： To compare argon laser photocoagulation and intrastromal injection of voriconazole as adjunctive treatment modalities in cases of resistant mycotic corneal ulcers. METHODS： Two groups each of them included 20 cases of resistant mycotic corneal ulcers. Both groups treated with local and systemic specific antimicrobial drugs guided with culture and sensitivity results. In one group argon laser photocoagulation was used as an adjunctive therapy to the specific antifungal drugs and in the other group, intrastromal injection of voriconazole was done besides the specific antifungal drugs. The 40 cases included in the study were proven according to culture and sensitivity to be 28 cases with pure fungal results and 12 cases with mixed （fungal and bacterial）. In argon laser group, argon laser irradiation of the corneal ulcer was performed using argon laser 532 nm wavelength （Carl Zeiss LSL 532s AG; Meditec, Inc.） after fluorescein staining. In the other group, voriconazole solution （500 pg/mL） was prepared and injected in the corneal stroma. All cases were followed up for 3mo after healing was achieved. RESULTS： Complete healing of the epithelial defect and resolution of stromal infiltration with no adverse effects were achieved in argon laser group in duration ranged from 2-4wk in 90% of cases. In voriconazole group 4 cases needed amniotic membrane graft due to thinning and 16 cases healed in duration ranged from 2- 6wk （80% of cases）. CONCLUSION： Argon superior to intrastromal treatment of resistant fungal laser photocoagulation is voriconazole injection in corneal ulcers.

Thoracoscopic internal mammary lymph nodes dissection: a staging tool for internal mammary lymph nodes in breast cancer

Objective： The aim of our study was to investigate the feasibility and safety of thoracoscopic internal mammary lymphadenectomy as a method to refine and thereby improve nodal staging in breast cancer. Methods： During the period from June 2004 to May 2007, 50 patients with operable breast cancer underwent modified radical mastectomy （MRM） or breast conserving surgery （BCS）, followed by thoracoscopic internal mammary lymphadenectomy, using 3 ports through the skin incision of the MRM or the BCS. Metal clips were used to mark precise site of lymphadenectomy. Results： of total number of 50 patients, the mean age of patients was 44 years （range, 27-60 years）. 40 （80%） had medio-central tumor, 10 （20%） had lateral tumor. 35 （70%） had clinically involved axillary nodes. 16 out of 50 patients received neo-adjuvant CTH. 44 patients underwent MRM and 6 patients underwent BCS. No intra-operative complications occurred. Atelectasis was the only postoperative complication that was encountered, which occurred in 12 cases, and was treated conservatively. The average chest drainage period was 1.2 day （range, 1-2 days）. The total number of IMN metastasis was 18 patients （36%）. The risk of IMN metastasis was higher; in younger patients （P = 0.03）, in medio-central tumors （P = 0.03）, in bigger tumors （P = 0.05）, with heavier metastasis of axillary LNs （P = 0.001）. But a correlation with the histological pattern of the lry tumor didn＇t exist （P = 1）. Knowing the IMN status helped in proper staging of patients, 7 patients showed evident stage migration after adding the IMN analysis to that of primary tumor and axillary LN. During the follow up period （the median, 22 months; range, 7 to 42 months）, no patient had pleural dissemination or port-site metastasis. Conclusion： Thoracoscopic IMN lymphadenectomy is a safe procedure, which can be done serious additional complications or cosmetic compromise. And allow proper nodal staging, which allow proper treatment planning.

Laparoscopic Repair of Perforated Duodenal Ulcer (Series of 50 Cases)

Background:?Perforated peptic ulcer is a common surgical emergency. The classic treatment is the mid-line laparotomy. However, laparoscopic treatment has been shown to be reliable. Few studies have evaluated its overall utility. The aim of this study is to assess the efficacy of laparoscopic repair of perforated duodenal ulcer.?Patients and Methods:?This study included 50 patients presented by perforated peptic ulcer between July 2009 and August 2014. They were submitted to laparoscopic omental patch repair with thorough peritoneal wash. Patients’ demographics, diagnostic techniques, management and outcome were evaluated. Results:?The mean age was 38.6 years with male to female ratio being 1.6:1. The perforation was diagnosed by plain X-ray abdomen in erect position in 43 patients and by abdominal CT scan in 7 patients. The laparoscopic repair of the perforation was successful in 48 patients while in 2 patients mid-line laparotomy was needed for proper control of the severe intra-abdominal sepsis. Post-operatively, all patients tolerated soft diet on the 3rd?post-operative day and full diet on the 4th?post-operative day. The mean duration of hospital stay was 4.5 days. Two patients developed post-operative intra-abdominal collection that was treated by ultrasound guided drainage, three patients developed umbilical port site wound infection while only two patients developed leakage, one of them reoperated after failed conservative surgery. No mortality was encountered in the study. Conclusion:?Laparoscopic repair of perforated peptic ulcer is a safe and reliable technique with accepted morbidity and mortality rates with all the advantages of the minimally invasive surgery.

Predictors of Gallstone Formation in Morbidly Obese Patients after Bariatric Surgery: A Retrospective Observational Study

Background: Obesity alone and rapid weight loss induced by bariatric surgery are recognized risk factors for the development of cholelithiasis. This study aimed to identify the predictive factors for gallstone formation after bariatric surgery. Patient and methods: The files of all morbidly obese patients underwent bariatric surgery in our unit during the period from March 2003 till October 2010 were reviewed and analyzed. All patients underwent routine preoperative ultrasonography and selective concomitant cholecystectomy was done in all patients with ultrasonographic-confirmed cholelithiasis. After excluding cases with prior and concomitant cholecystectomies, patients were divided into two groups;those who developed gallstones and those who did not and the two groups were compared. Results: Of the 143 reviewed files 135 were eligible to be included in the study. The incidence of cholelithiasis before surgery was 25.9% (35 cases). 19 cases (19%) of the 100 cases free at surgery developed gallstone at a mean of 13.2 months. Comparing the two groups, no significant difference was revealed regarding gender, age, preoperative BMI or type of the operation. But the percent of excess weight loss was significantly higher in the group that formed gallstones. Conclusion: Gender, age, preoperative BMI and type of the operation were not predictive of gallstones formation after bariatric surgery. The percent of excess weight loss was the only predictive postoperative factor.

Adult Intussusception in Patients with Peutz-Jeghers Syndrome: Case Series and Review of Literature

Background: Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant disorder characterized by gastrointestinal hamartomatous polyps and mucocutaneous pigmentations in the mouth, facial skin, hands & feet. Small bowel obstruction, intussusception, bleeding, intestinal and extra-intestinal malignancies are the major complications of PJS. The aim of this study is to analyze the clinical characteristics, preoperative diagnosis, and surgical management of PJS associated-intussusception in adults. Patients and Methods: This study included 5 cases with intussusception in PJS patients presented to Surgical Oncology Unit, General Surgery Department, Tanta University Hospital, Egypt and Hamad General Hospital, Hamad Medical Corporation, Qatar, between October 2011 and March 2016. Patients’ demographics were collected. After thorough clinical examination, abdominal X-ray, US, & CT scan were done. All the patients were submitted to midline laparotomy with resection anastomosis of the affected bowel segment. Results: The mean age was 28.4 years. Female: male ratio was 3:2. Abdominal pain was the most common presenting complaint with or without intestinal obstruction manifestations. Palpable abdominal mass was found in 3 patients (60%). Intussusception was proved pre-operatively in all the cases by abdominal ultrasound and CT scan. The intussusception was found in the jejunum in 3 patients, ileum in 1 patient, & in 1 patient, there was double intussusception (one jejunal & one ileo-cecal). Histopathological examination revealed the presence of typical Peutz-Jeghers hamartomatous polyp. No morbidity or mortality was reported at a mean follow-up period of 32 months. Conclusion: Family history, physical examination, abdominal ultrasound and CT scan were important in the diagnosis of acute intussusception caused by PJS. Surgical management of PJS associated intussusception is the recommended treatment to relieve patient’s symptoms and to avoid missing underlying malignancy. Patients with PJS should be followed up throughout their lives because of the increased risk of malignant changes.

Ultra-Pro Hernia System for Repair of Primary Complex Inguinal Hernia: Should It Be the Technique of Choice?

Purpose: The introduction of light weight three-dimension meshes into the field of inguinal hernia repair showed excellent outcomes. Ultrapro Hernia System (UHS) is one of these three-dimension meshes that allow reinforcing the pre-peritoneal space with minimal fixation. It improves the patient quality of life with rapid resumption of the daily activities. The aim of this study is to evaluate the short-term outcomes of open mesh repair of primary complex inguinal hernia using UHS mesh. Methods: Between November 2013 and November 2015, seventy five male patients with complex primary inguinal hernia were submitted to open inguinal hernia mesh repair using the UHS. Results: The mean age was 46.1 years. Thirty three patients had inguinoscrotal hernias, 14 with Nyhus type IIIA, 22 with Nyhus type IIIB, & 6 patients had strangulated hernias. The mean operative time was 48 minutes. No operative complications were recorded. Post-operatively, the mean VAS scale on 1 day, 1 week, & 1 month was 3.22, 1.2, & 0.3 respectively. The mean duration of oral analgesics use was 2.1 days. None of the patients reported any chronic pain at 12 months post-operatively. Two cases of superficial wound infection were recorded that were treated by oral antibiotics. No recurrence was reported during a mean follow-up period of 26 months. Conclusion: Inguinal hernia repair using UHS is an effective technique that combines the advantages of the anterior and the pre-peritoneal approaches. It improves the patient’s quality of life with minimal recurrence rates. A larger number of patients with longer follow up periods are needed to increase the validity of our results.

Wire-Guided Localization Biopsy for Non-Palpable Suspicious Breast Lesions

Background: About 25% - 35% of breast cancers are non-palpable at the time of diagnosis. Wire guided localization (WGL) had been considered as the standard technique for many years for excision of theses breast lesions. The aim of this study is to assess the efficacy of WGL biopsy in the management of non-palpable suspicious breast masses. Patients & Methods: This retrospective study concerned thirty female patients who were presented by non-palpable breast lesions as proved by mammography and complimentary ultrasonography between February 2013 and September 2014. According to BIRADS classification system, all the lesions were BIRADS III, IV and V. However, BIRADS I and II lesions and lesions proved to be benign were excluded from this study. The patients were submitted to WGL under local anesthesia. Then, they were shifted to the operating theatre, where they underwent WGL biopsy. The removed specimens were sent for radiological confirmation of complete excision. Then, it was sent for histopathological examination. Results: The mean age was 52.63 years. Eighteen patients (60%) were asymptomatic, 7 (23.3%) patients were with breast pain, and 5 patients (16.7%) had nipple discharge. Ten lesions (33.3%) were BIRADS III, 17 lesions (56.7%) were BIRADS IV, and 3 lesions (10%) were BIRADS V. The WGL was done by mammography in 19 patients (63.3%) and under ultrasonographic guidance in 11 patients (36.7%). No post-operative complications were reported. The mean tumor size was 11.23 mm and the mean safety margin of excision was 6.7 mm. IDC was found in 56.7% or cases, DCIS in 30%, and ILC in 13.3% of cases. 40% of the lesions were of grade I, 30% were of grade II, and 30% were of grade III. There were positive resection margins in 11 patients (36.7%). Conclusion: WGL biopsy is a safe and reliable surgical technique for management of non-palpable suspicious breast lesions. Special care should be paid for proper margin excision. However, WGL biopsy is technically demanding and needs learning curve for both the surgeon and the radiologist.

Short Term Outcomes of Laparoscopic versus Open Distal Gastrectomy with D2 Lymph Nodes Dissection for Gastric Cancer: A Prospective Study

Background: Laparoscopic distal gastrectomy (LDG) for gastric adenocarcinoma (GA) is gaining more acceptances worldwide. Its results are still controversial. This study aimed to assess short term outcomes of LDG and compare it to the standard open distal gastrectomy. Patients and Methods: 27 patients with GA of the distal 2/3 of the stomach were included and divided into 2 groups;Group A: 15 patients submitted to open distal gastrectomy with D2 lymph node (LN) dissection, and Group B: 12 patients submitted to LDG with D2 LN dissection. Results: The median age was 54 and 54.3 years in group A and B respectively. The median operative time was 118.7 and 210.2 minutes in group A and B respectively. The median safety margin was 6.52 and 5.7 cm in group A and B respectively while the median number of excised LN was 24.2 and 21.4 in group A and B respectively. One patient in group B had intraoperative bleeding that was controlled laparoscopically. No conversion to open surgery needed in group B. The median number of narcotic doses was 5.9 and 4.25 in group A and B respectively. The median length of hospital stay was 7.2 days in group A and 7.3 days in group B. Three patients in group A and 2 patients in group B had postoperative complications and all were treated successfully conservatively. Conclusion: LDG with D2 LN dissection is oncologically safe with short-term outcomes comparable to those of the open surgery. Gaining more surgeons’ experience is necessary to improve these results.

Short-Term Outcome of “Double Crown” Tackers Mesh Fixation in Laparoscopic Ventral Hernia Repair

Background:?Many ventral hernia repair methods have been described among surgeons. The traditional primary repair entails a laparotomy with suture approximation of strong fascial tissue on each side of the defect. However, recurrence rates after this procedure range from 12% to 24% during long-term follow-up. Laparoscopic ventral hernia repair (LVHR) is a well recognized minimally invasive surgical technique for repair of different types of abdominal wall ventral hernias. However, the best method of mesh fixation during LVHR is still a subject ofdebate.?Patients & Methods: In the present study, 50 patients were presented with ventral hernia between June 2012 and October 2013. Demographics of the patients were recorded. All patients were submitted to LVHR with mesh fixation by “Double Crown” of tackers. The first crown was placed on the mesh periphery with 1 cm between each 2 successive tackers and the second crown around the edges of the defect. Operative complications, VAS scale, post-operative complications, and length of hospital stay were reported. Results: The mean age was 40.08 years. Female to male ratio was 3:2. The mean BMI was 32.3. The diameter of the hernial defect was <5 cm in 64%, while, the defects larger than 15 cm were excluded. LVHR was successfully completed in all the patients with no conversion. Only 1 patient had intra-operative bleeding from omental vessels that was successfully controlled. The mean operative time was 79 minutes. Post-operatively, the mean VAS was 3.96, 2.12, and 0.24 at 24 hours, 2 weeks, and 4 weeks, respectively. Two patients developed post-operative ileus that was treated conservatively and 1 patient developed persistent seroma that was treated by repeated aspiration. The mean length of hospital stay was 3.08 days. Conclusion: “Double Crown” tackers mesh fixation in LVHR seems to be a safe and effective surgical technique with favorable outcome. However, further randomized studies are needed on larger numbers of patients to validate these results.

Role of diabetes mellitus on the recurrence rate of hepatocellular carcinomas after radiofrequency ablation in chronic hepatitis C patients

Aim:The aim was to assess the impact of hyperglycemia on the recurrence of hepatocellular carcinoma(HCC)as well as evaluate survival after curative ablation by radiofrequency.Methods:This study,which was conducted retrospectively on 107 chronic hepatitis C(CHC)patients with 159 HCCs,was presented to the Hepatology Unit of Internal Medicine Department at Tanta University Hospitals.All lesions were curatively treated by radiofrequency ablation(RFA)and the surveillance of HCC recurrence was evaluated radiologically every 3 months for periods between 6 and 36 months.Of 107 subjects,70 were males and 37 were females,with mean age 50.4±9.4 years.All patients were divided according to their glycemic state into the following three groups:Group I,which included 37 type 2 diabetic patients,with adequate maintenance of blood glucose,has 52 HCCs;Group II,which included 25 type 2 diabetic patients with inadequate maintenance of blood glucose,has 43 HCCs;and Group III,which included 45 euglycemic non-diabetic patients,has 64 HCCs.Results:Our results showed that,there was signifi cant increase in recurrence rate in diabetic patients with inadequate maintenance of blood glucose(Group II)compared to those in Group I and Group III(P<0.0001).Interestingly,there was no signifi cant difference concerning HCC recurrence between diabetic patients with adequate maintenance of blood glucose(Group I)and non-diabetic euglycemic patients(Group III).Our results also identifi ed that,inadequate maintenance of blood glucose in diabetic patients was also a signifi cant predictor of poor survival.Conclusion:Inadequate maintenance of blood glucose in diabetic patients is a signifi cant risk factor for recurrence of HCC and for poor survival after curative RFA therapy in CHC patients.