Ahmed Abdallah

Liver fibrosis: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL).

Liver fibrosis is a common pathway leading to cirrhosis, which is the final result of injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Liver biopsy has been considered to be the “gold standard” to assess fibrosis. However, liver biopsy being invasive and, in many instances, not favored by patients or physicians, alternative approaches to assess liver fibrosis have assumed great importance. Moreover, therapies aimed at reversing the liver fibrosis have also been tried lately with variable results. Till now, there has been no consensus on various clinical, pathological, and radiological aspects of liver fibrosis. The Asian Pacific Association for the Study of the Liver set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The process for the development of these consensus guidelines involved the following: review of all available published literature by a core group of experts; proposal of consensus statements by the experts; discussion of the contentious issues; and unanimous approval of the consensus statements after discussion. The Oxford System of evidence-based approach was adopted for developing the consensus statements using the level of evidence from 1 (highest) to 5 (lowest) and grade of recommendation from A (strongest) to D (weakest). The consensus statements are presented in this review.

Clinical Utility of Bronchoalveolar Lavage Pepsin in Diagnosis of Gastroesophageal Reflux among Wheezy Infants

Background. There is no gold standard test for diagnosis of gastroesophageal reflux disease (GERD) associated infantile wheezing. Objectives. To evaluate the value of bronchoalveolar lavage (BAL) pepsin assay in diagnosis of GERD in wheezy infants. Methods. Fifty-two wheezy infants were evaluated for GERD using esophageal combined impedance-pH (MII-pH) monitoring, esophagogastroduodenoscopy with esophageal biopsies, and BAL pepsin. Tracheobronchial aspirates from 10 healthy infants planned for surgery without history of respiratory problems were examined for pepsin. Results. Wheezy infants with silent reflux and wheezy infants with typical GERD symptoms but normal MII-pH had significantly higher BAL pepsin compared to healthy control (45.3 ± 8.6 and 42.8 ± 8 versus 29 ± 2.6, P < 0.0001 and P = 0.011, resp.). BAL pepsin had sensitivity (61.7%, 72 %, and 70%) and specificity (55.5%, 52.9%, and 53%) to diagnose GERD associated infantile wheeze compared to abnormal MII-pH, reflux esophagitis, and lipid laden macrophage index, respectively. Conclusion. A stepwise approach for assessment of GERD in wheezy infants is advised. In those with silent reflux, a trial of antireflux therapy is warranted with no need for further pepsin assay. But when combined MII-pH is negative despite the presence of typical GERD symptoms, pepsin assay will be needed to rule out GERD related aspiration.

Hormone Receptors and Age Distribution in Breast Cancer Patients at a University Hospital in Northern Egypt

Introduction Breast cancer is the most common cancer among Egyptian women. The disease is often advanced at diagnosis. Since molecular profiling is not feasible in routine practice, we sought to examine the association of age distribution with hormone receptor profile, disease stage and outcome among Egyptian women. Patients and Methods We conducted a retrospective review of breast cancer patients treated at Mansoura University Cancer Center in the Nile Delta from 2006 through 2011. Age groups were examined in relation to hormone receptors status and tumor clinicopathological criteria. Additionally, the effect of receptor status on disease relapse and disease-free survival was examined with logistic regression and Kaplan–Meier analysis. Results A total of 263 patients were included in the current analysis. About 66.9% (n = 176) of patients were hormone receptor positive, 14.1% (n = 37) were Her2/neu positive, and 19.0% (n = 50) were triple negative. Median age of the patients was 52 years and was equal across all receptor status types. Triple negative status correlated with increased risk of disease relapse (odds ratio = 1.8, P = 0.03) and with shortened disease-free survival (hazards ratio = 2.6, P < 0.01). Conclusion The age distribution and receptor status pattern in the Nile Delta region does not explain the aggressive behavior of the disease. The age of the patients at diagnosis is older than patients in earlier studies from Egypt emphasizing the importance of implementing mammographic screening programs.

Absence of Neck Scars With Total Endoscopic Submandibular Sialadenectomy Using a Chest Wall Approach: A New Technique

Introduction. This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total endoscopic submandibular sialadenectomy through a chest wall approach without the creation of any neck incisions. Methods. Four patients with benign submandibular gland lesions underwent a total endoscopic submandibular sialadenectomy through a chest wall approach using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments). Results. The operative time ranged from 140 to 170 minutes. Conversion to the open technique was only necessary in one case with good visualization of the facial vein and artery, marginal mandibular and lingual nerve. No significant perioperative complications were encountered. All patients were discharged on the third postoperative day, and they were satisfied with the cosmetic outcome. Conclusion. Total endoscopic submandibular sialadenectomy through a chest wall approach is technically feasible and safe with satisfactory cosmetic results. It may be a valid alternative to conventional surgery when performed in select patients. The absence of neck scars and the ability to avoid potential nerve injuries are the most obvious advantages of this innovative technique.

The Impact of Obesity on Performing Lymphadenectomy and Its Outcome in Ovarian Cancer Patients

Background: This study discusses the effect of obesity on the number of lymph nodes harvested during systematic LND and the LND-related complications in ovarian cancer patients. Methods: This retrospective study enrolled women with ovarian cancer who were consecutively subjected to open surgical resection that included systematic LND (pelvic and para-aortic) in the Oncology Center in Mansoura University (OCMU) during the period between January 2012 and June 2017. Patients were categorized according to the recommendations of World Health Organization by their BMI as non-obese (BMI 30.0 kg/m2) and obese (BMI ≥ 30.0 kg/m2). Results: Seventy-seven women with ovarian cancer were enrolled in the study according to our inclusion and exclusion criteria. 43 females (55.8%) were grouped as obese and 34 (44.2%) as non-obese. Lymph nodes retrieved in total and in different stations separately (pelvic and para-aortic) were all similar among patients in both groups. LND-related intraoperative complications were observed in 8 patients (18.6%) in the obese group and 3 patients in the non-obese group (8.8%) (P = 0.347). Hospital stay was the same in the two groups with a median of 4 days (IQR 3 - 5). Postoperative complications occurred in 13 patients (30.2%) in the obese group and only in one patient (3%) in the non-obese group (P = 0.004). Conclusion: Obese ovarian cancer patients may safely undergo comprehensive staging involving extensive lymph node dissection in open surgeries without significant increase in the rates of intraoperative complications. Whereas, postoperative complications (wound infection and thromboembolic events) tend to occur at higher rates with obese patients. Trial registration: This study was retrospectively registered and approved at faculty of Medicine Mansoura University, Egypt with IRB approval number R.18.02.46.

Evaluation of gastro-oesophageal reflux disease in wheezy infants using 24-h oesophageal combined impedance and pH monitoring

BACKGROUND AND STUDY AIMS Gastro-oesophageal reflux disease (GERD) is incriminated as a cause of non-asthmatic infantile wheeze. To date, no diagnostic test is considered standard for GERD-related airway reflux diagnosis. Oesophageal combined multiple channel intraluminal impedance and pH (MII-pH) monitoring is proposed to be a sensitive tool for evaluation of all GERD including infantile wheeze. We aimed to determine the GERD prevalence amongst wheezy infants in the first year of life using combined MII-pH versus pH monitoring alone and evaluate the sensitivity and specificity of objective MII-pH monitoring parameters in GERD-associated infantile wheeze diagnosis compared to those of lipid-laden macrophage index (LLMI). PATIENTS AND METHODS Thirty-eight wheezy infants below 1year of age were evaluated for GERD using oesophageal combined MII-pH monitoring and LLMI. RESULTS Totally, 60.5% of cases had abnormal MII-pH; only 7.9% of them had abnormal pH monitoring. LLMI was significantly higher in wheezy infants with abnormal MII-pH than infants with normal MII-pH monitoring (112±88 versus 70±48; P=0.036). The current definitions of abnormal MII-pH study, reflux index≥10% and distal reflux episodes≥100, had low sensitivity (23%) but high specificity (100% and 96%, respectively) in GERD-related aspiration diagnosis defined by LLMI≥100. Using ROC curves, bolus contact time≥2.4% and proximal reflux episodes≥46 had 61% and 54% sensitivity and 64% and 76% specificity, respectively, in GERD-related aspiration diagnosis. CONCLUSION Combined MII-pH is superior to pH monitoring in reflux-associated infantile wheeze diagnosis. Objective data including proximal reflux episodes and bolus contact time should be combined with the current parameters used in reflux-associated infantile wheeze diagnosis.

Gastro-esophageal Reflux Disease Associated Infantile Wheezing; Phenotype Characteristics and Effect of Antireflux Medications.

To the Editor: Gastro-esophageal reflux disease (GERD) is incriminated as one of the several causes of nonasthmatic wheezing in infants [1]. GERD aggravates airway diseases via direct micro-aspiration and neural mechanisms [2, 3]. However, the presence of GERD in a wheezy infant may be a coincidence or secondary to wheezing and its medications [4]. To evaluate GERD-infantile wheezing relationship and the role of antireflux medications in wheeze management, we prospectively evaluated 52 wheezy infants for the presence of GERD using esophageal combined multiple channel intraluminal impedance and pH (MIIpH) monitoring, esophagogastroduodenoscopy with esophageal biopsies and bronchoalveolar lavage (BAL) pepsin and leukocytes content. Abnormal pH study was defined by reflux index ≥10 % in infants ≤ one year or ≥5 % in infants > one year and abnormal MII when the total number of reflux episodes was ≥100 in infants below one year or ≥73 in infants above one year, ref lux-cough symptom index ≥50 %, symptom sensitivity index ≥10 % or symptom association probability ≥95 % [5]. Furthermore, wheezy infants with abnormal combined MII-pH or reflux esophagitis were given domperidone (0.2 mg/kg/dose, 3 times/d) and omeprazol (10 mg once daily) for 12 wk and then reevaluated for symptom control and exacerbation recurrence. Thirty eight infants (73 %) had GERD [34 (65.4 %) had abnormal combined MII-pH; 7 (13.5 %) with abnormal pH, 33 (63.5 %) with abnormal MII studies and 18 (34.6 %) had reflux esophagitis in esophageal biopsies]. Among wheezy infants with GERD, those with silent pathological reflux had significantly more severe exacerbation episodes (58 %; P = 0.034), significantly higher BAL pepsin (45.3 ± 8.6; P = 0.012) and significantly higher lipid laden macrophage index (128 ± 68; P = 0.02). Continuous wheeze pattern and silent reflux were significant predictors of severe exacerbation episodes [RR (95 % CI): 6.189(1.27–30.153) and 14(1.25– 157) respectively; P = 0.024 and 0.034, respectively]. The frequency of exacerbation episodes was significantly reduced during therapy even in wheezy infants with poor symptom control compared to the preceding 3 mo (5.2 ± 1.1 vs. 7.2 ± 3.4; P = 0.014). Wheezy infants with GERD and poor response to anti-reflux medications had significantly higher BAL pepsin level before starting treatment than wheezy infants with good response to anti-reflux medications (48 ± 7.3 vs. 37.3 ± 9.4; P = 0.008). We conclude that, although GERD has a high prevalence among wheezy infants, only silent pathological reflux contributes to severe wheeze exacerbation episodes. Prescription of antireflux medications to wheezy infants with GERD lowers the episodes of wheeze exacerbations especially in those with low BAL pepsin levels. * Ahmed Zaki drahmedmd17@yahoo.com

Surgical Management of Adenocarcinoma of the Pancreatic Uncinate Process in a Cancer Hospital in Egypt

Introduction Pancreatic carcinoma affecting the uncinate process is a challenging surgical condition. Several considerations affect the management plan, including the need for vascular resection and the ability to achieve a clear margin. Methods The data of 19 patients who had curative resection for pancreatic adenocarcinoma of the uncinate process were reviewed. Operative mortality and morbidity, and disease-free survival (DFS) were calculated. Results The study population included 13 male and 6 female patients with a mean age of 55 years. Nine patients (47.4%) had stage I disease, seven patients (36.8%) had stage II disease, and three patients (15.8%) had stage III disease. A total of 12 patients had Whipple procedure and 7 patients had total pancreatectomy. In total, there were 9 R0 and 10 R1 resections. Operative mortality rate was 10.5% (2/19), postoperative leakage rate was 21.1% (4/19), and wound sepsis rate was 21.1%. Median DFS was 19.2 months. Survival was superior in the Whipple procedure group than in the total pancreatectomy group (median survival 19 months vs 4 months, respectively). Vascular resection and retroperitoneal safety margin status did not affect disease relapse. Conclusion Non-metastatic pancreatic adenocarcinoma of the uncinate process should be offered R0 or R1 resection whenever technically feasible.