Ahmed Samy El-Agwany

Comparative study between benzydamine hydrochloride gel, lidocaine 5% gel and lidocaine 10% spray on endotracheal tube cuff as regards postoperative sore throat.

Postoperative sore throat is a common complication after endotracheal intubation. After tracheal intubation, the incidence of sore throat varies from 14.4% to 50%. The aim of the study was to compare between benzydamine hydrochloride gel, lidocaine 5% gel and lidocaine 10% spray on the endotracheal tube cuff as regards postoperative sore throat. The present study was carried out on 124 patients admitted to Alexandria university hospitals for lumbar fixation surgery requiring general anesthesia. Patients were randomly allocated into 4 groups. Benzydamine hydrochloride gel, 5% lidocaine hydrochloride gel, 10% lidocaine hydrochloride spray, or normal saline were applied on endotracheal tube cuffs before endotracheal intubation. The patients were examined for sore throat (none, mild, moderate, or severe) at 0, 1, 6, 12, and 24h after extubation. The results were collected, analyzed and presented in table and figure. The highest incidence of postoperative sore throat occurred at 6h after extubation in all groups. There was a significantly lower incidence of postoperative sore throat in the benzydamine group than 5% lidocaine gel, 10% lidocaine spray, and normal saline groups. The benzydamine group had significantly decreased severity of postoperative sore throat compared with the 10% lidocaine, 5% lidocaine, and normal saline groups at observation time point. Compared with the 5% lidocaine the 10% lidocaine group had significantly increased incidence and severity of postoperative sore throat after extubation. Compared with normal saline the 10% lidocaine group had increased incidence of postoperative sore throat. There were no significant differences among groups in local or systemic side effects. So in conclusion, benzydamine hydrochloride gel on the endotracheal tube cuff is a simple and effective method to reduce the incidence and severity of postoperative sore throat. Application of 10% lidocaine spray should be avoided because of worsening of postoperative sore throat where incidence increased but not the severity in relation to 5% lidocaine gel. Applying 5% lidocaine on the endotracheal tube cuff does not prevent postoperative sore throat but its application is better than lidocaine 10% spray or saline.

Estudo comparativo entre cloridrato de benzidamina em gel, lidocaína a 5% em gel e lidocaína a 10% em spray no balonete do tubo endotraqueal em relação à dor de garganta pós‐operatória

Postoperative sore throat is a common complication after endotracheal intubation. After tracheal intubation, the incidence of sore throat varies from 14.4% to 50%. The aim of the study was to compare between benzydamine hydrochloride gel, lidocaine 5% gel and lidocaine 10% spray on the endotracheal tube cuff as regards postoperative sore throat. The present study was carried out on 124 patients admitted to Alexandria university hospitals for lumbar fixation surgery requiring general anesthesia. Patients were randomly allocated into 4 groups. Benzydamine hydrochloride gel, 5% lidocaine hydrochloride gel, 10% lidocaine hydrochloride spray, or normal saline were applied on endotracheal tube cuffs before endotracheal intubation. The patients were examined for sore throat (none, mild, moderate, or severe) at 0, 1, 6, 12, and 24h after extubation. The results were collected, analyzed and presented in table and figure. The highest incidence of postoperative sore throat occurred at 6h after extubation in all groups. There was a significantly lower incidence of postoperative sore throat in the benzydamine group than 5% lidocaine gel, 10% lidocaine spray, and normal saline groups. The benzydamine group had significantly decreased severity of postoperative sore throat compared with the 10% lidocaine, 5% lidocaine, and normal saline groups at observation time point. Compared with the 5% lidocaine the 10% lidocaine group had significantly increased incidence and severity of postoperative sore throat after extubation. Compared with normal saline the 10% lidocaine group had increased incidence of postoperative sore throat. There were no significant differences among groups in local or systemic side effects. So in conclusion, benzydamine hydrochloride gel on the endotracheal tube cuff is a simple and effective method to reduce the incidence and severity of postoperative sore throat. Application of 10% lidocaine spray should be avoided because of worsening of postoperative sore throat where incidence increased but not the severity in relation to 5% lidocaine gel. Applying 5% lidocaine on the endotracheal tube cuff does not prevent postoperative sore throat but its application is better than lidocaine 10% spray or saline.

Conservative treatment of placenta previa accreta with cervical isthmic opposition suturing followed by bilateral internal iliac artery ligation

exact test, and Pb0.05 was considered statistically significant. No difference inH. pylori or CagA IgG seropositivitywas demonstrated between the two groups (Table 1). The present results contradict the findings of previous studies [3,4]. This is probably a result of other factors, some unknown, having the potential to disturb placental function during early pregnancy. That the study was conducted in one region, with a convenience sample of a fairly small number of participants, is a limitation of the present investigation, which found that H. pylori infection was not associated with pre-eclampsia.

Bilateral Absence of Common Iliac Artery: Abnormal anatomical variation of the Internal Iliac Artery During Ligation in Conservative Surgical Management of Placenta Previa Accreta

BackgroundAbnormal placental invasion has increased with persistent rise in cesarean delivery. Management depends on accurate diagnosis, and delivery should be planned at an institution with appropriate expertise and resources. Hemorrhage in pregnancy is the leading cause of maternal mortality in developing countries. Internal iliac artery ligation is one of the lifesaving procedures in intractable pelvic hemorrhage. The vascular malformations involving the abdominal aorta, common iliac artery and its branches are very rare.CaseWe present a case of placenta accreta which is a major risk for peripartum deaths. In this case, we tried to explain our conservative surgical approach in the form of cervico-isthmical transverse opposition suture with bilateral internal iliac artery ligation. Normally, the abdominal aorta bifurcates into the right and left common iliac arteries anterolateral to the fourth lumbar vertebra. In the present case, there was bilateral absence of common iliac arteries which are the terminal branches of the abdominal aorta. Internal iliac artery was extremely long and equal size to external one. The reason for the absence of common iliac artery may be attributed to the disappearance of the initial segment of the umbilical artery.ConclusionCesarean section and placenta previa are significant risk factors for placenta accreta which is associated with high fetomaternal morbidity and mortality. In order to avoid postpartum hemorrhage and fertility loosing hysterectomy, our approach which consists of bilateral hypogastric arterial ligation and transverse compression sutures in the lower uterine segment can be applied successfully. Proper identification of anatomical variations in pelvic vasculature is essential for surgical and radiological interventions to prevent complications. This article aims at sharing author’s experience about the anatomical variation of the artery especially long ones as in absent common iliac artery or even a high bifurcation.

Secondary Advanced Abdominal Pregnancy after Suspected Ruptured Cornual Pregnancy with Good Maternal Outcome: A Case with Unusual Gangrenous Fetal Toes and Ultrasound Diagnoses Managed by Hysterectomy

Incidence of abdominal pregnancy is accounting for 1.4% of all ectopic pregnancies. This is a rare case report of a 35-year-old multigravida who was presented to our hospital at 24 weeks of gestation with advanced live intraabdominal pregnancy diagnosed by ultrasound. The patient was followed up till 28 weeks in hospital for medicolegal viability in Egypt. Midline laparotomy was done, a live baby was delivered, and hysterectomy was done for attached placenta. Mother was discharged in good health, and baby was admitted in neonatal intensive care unit with no congenital anomalies and died after three weeks of sepsis. The management of advanced abdominal pregnancy remains controversial. Diagnosis and management of advanced abdominal pregnancy is still a challenge to today’s medical world. But high index of suspicion aided with imaging studies can help in timely diagnosis, thereby preventing the associated life-threatening complications.

Recurrent Bilateral Mucinous Cystadenoma: Laparoscopic Ovarian Cystectomy with Review of Literature

The second most common epithelial tumor of the ovary is the mucinous tumors, and it constitutes about 8–10% of all ovarian tumors. The recurrence of mucinous cystadenoma is very rare after complete excision. Few cases have been reported. The case presented had initial surgery for adenxal mass diagnosed as mucinous tumor, performed by laparotomy and was followed up. After recurrence, the patient underwent laparoscopic evaluation and bilateral ovarian cystectomy was performed as a fertility preservation for the patient young age. The histopathological diagnosis was mucinous cystadenoma, the same as the initial one. Management in young patients is challenging, especially in the case of recurrence. Follow-up of these patients is very important and transvaginal ultrasound seems to be currently the most effective diagnostic tool for the follow-up of young patients treated with cystectomy for benign mucinous cystadenomas. Total hysterectomy and bilateral salpingo-oophorectomy is recommended after completing family size or reaching age of 35 for fear of progression or incompliance.

Disseminated Peritoneal Leiomyomatosis and Metastatic GIST: Differential Diagnosis Dilemma Regarding Multiple Nodular Serosal Lesions and Management

AbstractAim We aim to discuss cases with gastrointestinal stromal tumor and leiomatosis peritoneal dissemeniata LPD regarding their diagnosis and surgical management with pitfalls related. We also aim to focus on management of multiple nodular serosal lesions.Method Two cases are presented. Both were diagnosed as advanced ovarian cancer on CT and ultrasound imaging by multiple nodular peritoneal lesions, omental cake and adnexal masses. Tumor markers were normal in both cases. Both were scheduled for exploratory laparotomy. One patient diagnosed with neurofibromatosis type I.ResultsMidline laparotomy was done for one case revealing normal adnexa with multiple fibroid uterus, peritoneal solid masses with large mesenteric and omental masses related to the small intestine. Total hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and resection anastomosis for the small intestine with removal of macroscopic lesions were done. Midline line laparotomy was done for the second case revealing free adnexa with subserous vascular fibroids and omental fibroid solid masses. Total hysterectomy with bilateral salpingo-oophorectomy and total omentectomy and removal of macroscopic peritoneal lesions seen were done. The second case was diagnosed as Disseminated Peritoneal Leiomyomatosis, and the other case was diagnosed with multiple uterine fibroid and metastatic GIST on histopathology.ConclusionDisseminated Peritoneal Leiomyomatosis and metastatic GIST can be similar on imaging and operative findings. Also they are similar to other lesions especially peritoneal carcinomatosis as in advanced ovarian cancer. These pathologies should be kept on mind when encountering multiple solid nodular masses in the visceral and parietal wall peritoneum and the omentum on imaging and intra-operative especially with normal associated tumor markers of ovarian cancer as serum CA125. Surgical and postoperative management differ according to the pathology. These pathologies should be confirmed by histopathology and immunohistochemistry. Frozen section is highly needed in these cases to optimize management.

Laparoscopy and computed tomography imaging in advanced ovarian tumors: A roadmap for prediction of optimal cytoreductive surgery

Introduction: Comprehensive staging laparotomy and cytoreductive surgery followed by chemotherapy has been the standard of care in advanced ovarian cancer. Neoadjuvant chemotherapy is an alternative in inoperable advanced cases. To select patients amenable for successful cytoreduction, major determinants including CT imaging and laparoscopy could be of value. There is no general accepted model for selection and reproducibility of techniques are a major challenge due to different clinical practice and complexity of scoring systems. Some lesions as small size (<5 mm) peritoneal deposits and mesenteric affection are hard to see on CT so, complementary laparoscopy may play a role in the preoperative assessment. The aim of this study was evaluation of the role of laparoscopy in advanced ovarian tumors for prediction of optimal cytoreductive surgery in relation to CT and surgical peritoneal carcinomatosis index (PCI). Aim: Was to evaluate laparoscopic assessment in advanced ovarian tumors for prediction of optimal cytoreductive surgery in relation to CT and surgical peritoneal carcinomatosis index (PCI). Setting: Gyne-oncology specialized center, El-Shatby maternity university hospital, Alexandria Egypt. Methods: From January 2016 to December 2016, 15 patients were recruited from gyne-oncology specialized center, Alexandria, Egypt. Patients underwent a special design described later then laparoscopy using palmar point entry was done for assessing small lesions and the extent of affection in surface peritoneal, mesentery, serosa of the gut especially small intestine (terminal ileum affection, more or less than 50% affection) mainly with evaluating other sites as liver surface and diaphragm peritoneal surface affection after removal of ascites by aspiration. Findings were correlated with laparotomy and CT scan findings. Surgery was performed in the same setting which is better or with in two weeks. Results: There were two cases with upper abdominal surgeries (cholecystectomy and splenectomy) where no visualization of liver and stomach on laparoscopy but were free on CT scan and surgical evaluation. Douglas pouch was not assessed in two patients with large fixed bilateral ovarian masses on laparoscopy. Two cases with diaphragmatic affection on CT scan related to the posterior surface were not detected on laparoscopy. These findings were correlated with surgical findings as the gold standard. The pathology was ranging from low grade to high grade serous cyst adenocarcinoma. Conclusions: Laparoscopic evaluation is a useful adjunct with CT prior to performing ovarian cancer cytoreductive surgery for assessment of operability. Laparoscopy is better for evaluating extent of serosal affection in advanced tumors in cases with omental cakes on CT. A roadmap for prediction of operability in advanced ovarian cancer can be used by combing CT PCI and laparoscopic assessment.

Value and best way for detection of Sentinel lymph node in early stage endometrial cancer: Selective lymphadenectomy algorithm

INTRODUCTION The cornerstone of treatment for endometrial carcinoma is total abdominal hysterectomy and bilateral salpingo-oophoprectomy. Pelvic lymphadenectomy, with or without para-aortic lymphadenectomy, plays an important role in the surgical staging of endometrial carcinoma, and provides more accurate prognostic information. AIMS We aimed to evaluate the value and techniques for SLN mapping in early stage endometrial cancer with low risk for lymph node metastasis and whether selective or systematic lymphadenectomy is needed according to the results of proposed algorithm. METHOD Between June 2016 and June 2017, 120 patients with early stage endometrial cancer with low risk for nodal metastasis underwent surgical staging. Patients were classified equally according to SLN mapping technique used for injecting the methylene blue dye. Group A included hysteroscopic guided methylene blue injection, Group B included transcervical injection, Group C included subserosal uterine injection and Group D included combined transcervical and subserosal injection. Blue lymph nodes and enlarged suspicious whether stained or non stained ones were dissected for frozen section evaluation done then bilateral pelvic node dissection was done and tissues were sent for pathological examination. RESULTS Clinical and pathological SLN detection were more with hysteroscopic technique than others and pathological detection was lower than clinical detection in all techniques. Metastatic disease was more common in nodes with suspicious appearance. About 10% of negative suspicious and mapped nodes were associated with positive other nodes for metastasis. CONCLUSION SLN in endometrial cancer has a role in staging of endometrial cancer with best technique for detection, hysteroscopic guided blue dye injection. SLN can be used in patients with low risk for lymph node metastasis for selective lymphadenectomy. Blue dye labelling using methylene blue dye is good in low resource countries as it is cheap. We recommended the following algorithm for surgical staging in early endometrial cancer with better results than using SLN alone. Stage I type 1, grade 1,2 endometrial cancer should undergo surgical staging with initial evaluation of the peritoneum which if affected, it is stage III with no need for lymphadenectomy. Then, dissection of the blue and suspicious nodes which if any is positive on frozen section, selective same side pelvic and paraaortic nodal dissection should be done. If they are negative, no need for lymphadenectomy. This approach can help patients to avoid the side effects associated with a complete lymphadenectomy. The higher rate of detection using this algorithm is related to combining the suspicions nodes with the stained ones.

Considerable observations in cesarean section surgical technique and proposed steps

As with most surgical procedures, there is no standard technique for cesarean delivery [1]. Cesarean delivery is often cited as the most common major surgical procedure performed in an operating room in the United States and more than 55% of deliveries in Egypt are by cesarean section [2]. We have some observations that were noticed during our practice over years regarding cesarean section operative findings and surgical technique. We also proposed some steps to be considered during cesarean section that could be beneficial. We would like to share our observations with colleagues to be evaluated and discussed. One of the common observations encountered during cesarean section was the thinned out (filmy) lower uterine segment (LUS) that was noted in patients with history of previous cesarean section (CS) than those with history of vaginal delivery, with more bleeding and ballooning of the lower segment (atonic LUS) in these cases [3]. We can explain this by poor muscle layer development in the LUS due to low blood supply in this region during the healing phase (This was evidenced by no decidua formation and only amnion layer is seen in the next pregnancy in the LUS). Decidua does not develop below the uterine incision in the thin LUS due to low blood supply. The explanation for the low blood supply is that full-term pregnancy is associated with thick LUS as commonly encountered in uterine incision in virgin uterus, where transverse incision is done which interrupts blood supply to the area below. We interrupt the continuity of vessels and blood supply is already low below especially if uterine vessels are transected during the section by extension of the incision. Therefore, the thinned out segment with poor muscle development will not contract with ballooning with blood and fresh intraoperative vaginal bleeding will occur. It can be recommended to avoid the decrease in blood supply in the LUS by avoiding uterine artery injury by incision extension, using Smiley incision, uterine incision at the urinary bladder demarcation, and not low down near the cervix. Plication of the LUS can be done if ballooning occurred or thinning out of LUS is encountered after sharp dissection of the urinary bladder to guard against intraoperative and postoperative uterine bleeding. Another observation is that healing in the LUS will need excess blood supply as it is already diminished after the incision which is assumed to be gained in some cases from adhesions of urinary bladder high up to or covering the incision site and this can occur even with no visceral peritoneum closure in the previous pregnancy. Blood supply can be gained also through the anterior abdominal wall so, if high up urinary bladder or abdominal wall uterine adhesions are encountered in CS, one can consider thinned out LUS and expect ballooning (atony LUS) after dissection. Another observation is that uterine incision at the same uterine scar which is already near the cervix from previous delivery is commonly related to emergency previous section (in active phase of labour) more than elective one. This is also associated with thinned out LUS. If the decidua and fetal membranes are extending below the uterine incision, this indicates vascularized thin LUS with low incidence of bladder and abdominal wall adhesions. Another observation is that single layer uterine closure may be associated with uterine abdominal wall adhesions as everted uterine edges on closure and no second layer inverting suture. We can propose suturing parietal and visceral peritoneum to avoid raw surface area for adhesions especially in vascularized oozing beds. Some questions need to be evaluated as whether resuturing of bladder flap after bladder dissection in previous section is needed? and * Ahmed Samy El-Agwany Ahmedsamyagwany@gmail.com; ahmed.elagwany@alexmed.edu.eg