Ashraf Khater

Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection

BackgroundReconstruction of large scalp defects after tumor resection is a challenging problem. We aimed at putting an algorithm for reconstruction of those defects.MethodsForty-two patients with scalp malignancies were enrolled in this study. Tumors were resected to a 1 cm negative margin and defects were reconstructed according to their size and to patient general condition.ResultsNo peri-operative mortality was encountered. Usage of free flaps was superior in cosmoses and function with an acceptable rate of complications.Conclusionfor scalp defects wider than100 cm2, the best tool of reconstruction is free flaps. Pedicled distant flaps are reserved if free flaps are not feasible or failed. Split thickness skin grafts are cosmetically inferior and not suitable for recurrent and irradiated tumours and better reserved for patients who cannot tolerate major operations.

Pharyngoesophageal reconstruction after resection of hypopharyngeal carcinoma: a new algorithm after analysis of 142 cases

BackgroundThe aim of this study is to define an algorithm for the choice of reconstructive method for defects after laryngo-pharyngo-esophagectomy for hypopharyngeal carcinoma.MethodsOne hundred and forty two cases of hypopharyngeal carcinoma were included and operated on by either partial pharyngectomy, total pharyngectomy or esophagectomy. The reconstructive method was tailored according to the resected segment.ResultsPectoralis flap was used in 48 cases, free jejunal flap in 28 cases, augmented colon bypass in 4 cases, gastric pull up in 32 cases and gastric tube in 30 cases. Mean hospital stay was 12 days. Mortality rate was 10.6% and morbidity rate was 31.7%. Total flap failure occurred in 3 cases of free flap and one case of pectoralis flap. There were 23 cases of early fistula. Late stricture occurred in 19 cases, being highest with myocutaneous flap (early fistula 12/50 and late stricture 13/50).ConclusionFree jejunal flap was the flap of choice for reconstruction when the safety margin is still above the clavicle. In cases with added esophagectomy, we recommend gastric tube as a method of choice for reconstruction.

Therapeutic reduction mammoplasty in large- breasted women with cancer using superior and superomedial pedicles

BACKGROUND Surgical management of breast cancer in large-breasted women presents a real challenge. This study aims to evaluate the outcome of therapeutic reduction mammoplasty in large-breasted women with breast cancer using superior and superomedial pedicles, situated at any breast quadrant except for the central and upper medial quadrants. METHODS Fifty women with breast cancer and large breasts underwent simultaneous bilateral reduction mammoplasty. The weight of the tissue removed ranged from 550 g to 1050 g and the tumor-free safety margins by frozen section were in the range of 4 cm to 12 cm. RESULTS The age of the patients ranged from 36 to 58 (median 43) years and tumor size ranged from 1 cm to 4 cm. The cosmetic outcomes were excellent in 32 patients (64%), good in 15 (30%) patients, and fair in three patients (6%). The follow-up period was 8-36 (mean 20) months, with no local recurrence or systemic metastasis. CONCLUSION Therapeutic reduction mammoplasty using superior and superomedial pedicles was shown to be oncologically safer than traditional conservative surgery. This oncoplastic procedure yields a satisfactory esthetic outcome with lower morbidity in large-breasted women with breast cancer.

Tumescent mastectomy: the current indications and operative tips and tricks

Background Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a diluting saline solution that makes flaps firm and tense, thus minimizing systemic drugs toxicity and making surgery possible with minimal bleeding. This technique is very useful in elder women and those with American Society of Anesthesiologists; score III and IV. The objective was to establish an alternative safe technique to general anesthesia in some selected mastectomy patients. Patients and methods Twenty candidate women for total mastectomy and axillary dissection were enrolled and consented to participate. After preparation, an anatomically directed infiltration was made under sedation, using a cocktail of lidocaine, bupivacaine, and epinephrine, followed after 20 minutes by the surgical incision and completion of mastectomy. All intraoperative and postoperative outcomes were recorded. Results Although 7 cases required added analgesic medications, no conversion for general anesthesia was recorded. Mean operative time was 81±15.8 minutes. Mean blood loss was 95.8±47.5 mL. There was no recorded intraoperative hemodynamic instability. Postoperative visual analog score was not exceeding 4 till the end of the first 24 hours. Opioids were not required in any case, and the mean dosage of Ketorolac used was 30±8.75 mg. Drains output and the incidence of postoperative complications were acceptable. Conclusion We can consider tumescent mastectomy in well-selected patients a safe alternative for performing mastectomy when general anesthesia is hazardous, with minimal blood loss and long lasting postoperative analgesia without an additive effect on the operative time, hospital stay, and intraoperative and postoperative complications.

Etiologic revelation and outcome of the surgical management of idiopathic granulomatous mastitis; An Egyptian centre experience.

INTRODUCTION Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory condition that is confused with cancer. It usually affects women in child bearing age. The exact aetiology and pathogenesis are still unknown, and the optimal therapeutic modality has not yet been established. Treatment most frequently includes Antibiotics, corticosteroids and immunosuppressant, surgical excision, and even mastectomy. MATERIAL AND METHODS We studied a thirty cases diagnosed with IGM in our locality to find out the leading risk factors and the outcome of our surgical approach which involves excision of the lesion in continuity with duct system. Patients demographic data, history related to lactation and outcome were recorded. RESULTS All patients were parous women with history of previous breast feeding for all kids. Twenty-six patients (86.66%) had a history of early incomplete nursing care to the affected breast. After our surgical approach, Twenty eight (93.3%) patients showed fast recovery with no detectable recurrences in the median follow up period (18 months) with acceptable cosmoses. CONCLUSION History of breast feeding together with early failure of complete nursing from a single breast is the most important risk factors for development of IGM in young aged women. Surgery plays an important role in treating IGM, however, it should be directed towards excision of the present mass (s) together with the pathological and colonized duct system.

Safety and esthetic outcomes of therapeutic mammoplasty using medial pedicle for early breast cancer

Background Although therapeutic mammoplasty (TM) was introduced for treatment of localized ductal carcinoma in situ and invasive breast carcinoma (stages I and II) in females with large breast size, the suitability of medial pedicle TM for treatment of breast tumors at different locations has not been established. The objective of this study was to assess the safety and esthetic outcome of medial pedicle TM for breast tumors at different locations. Methods The study was conducted from February 2012 to July 2014. Consecutive patients with early breast carcinoma with medium- and large-sized breasts, with or without ptosis, who were offered medial pedicle TM were included in the study. Patients who were not candidates for breast-conserving surgery or those with tumors located along the medial pedicle were excluded. All patients received immediate postoperative adjuvant chemoradiotherapy. Results Thirty patients with a mean age of 48.5 years received medial pedicle TM in the breast harboring the tumor or, additionally, the other breast (N=14). The tumors were in the upper (60.0%), lower (26.7%), and lateral (13.3%) quadrants. Minor complications occurred in five cases (5/30, 16.7%) in the ipsilateral and in two (2/14, 14.3%) contralateral breasts. No wound dehiscence or areolar necrosis was recorded. A total of 22 (73.3%) patients were scored as excellent cosmesis. After a median follow-up of 20 months, no locoregional recurrence or distant metastases were observed. Conclusion TM using a medial pedicle is a safe and appealing technique among women with tumors at different locations.

FEASIBILITY AND FUNCTIONAL OUTCOME OF LAPAROSCOPIC NERVE SPARING RADICAL HYSTERECTOMY.

ABSTRACT Aim: Evaluation of the feasibility of laparoscopic nerve sparing radical hysterectomy in comparison to the non-nerve sparing type. Methodology:Patient recruitment started from November 2014 to November 2016, patients who underwent laparoscopic type C1 hysterectomy and laparoscopic type C2 hysterectomy according to Querleu-Morrow classification(1) at our departments were prospectively evaluated. The inclusion criteria included: Patients with cervical carcinoma Stage IA2 to stage IIB cervical cancer according to FIGO staging and Stage II-III endometrial cancer with cervical involvement according to FIGO staging. Postoperative drainage of the bladder through a Foley catheter was maintained for 2 days and removed on the third day and the patients were asked to perform spontaneous voiding every 3 hours followed immediately by drainage of the bladder by urinary catheter to assess the post void residual (PVR) urine volume. The procedure was repeated until the PVR is less than 100 ml. The voiding function was considered normal when the patient had 2 consecutive measurements of PVR urine less than 100 ml and abnormal if the patient had a PVR urine more than 100 ml with need of self- catheterization after 4 weeks from the date of surgery. Results:46 patients were included in the study, 30 patients underwent type C1 LNSRH (Group A) and 16 patients underwent type C2 LRH (Group B). The mean age was 49.1±13.1 and 51.2±11.8, median BMI was 26.2(22.9-28.5) and 23.8(21-26.6) respectively for the 2 groups. The mean operative time was 240.1±65.5 in group A and 308.1±83 in group B (P value=0.004). The rate of intraoperative complications was 10% in group A and 12.5% in group B. The median duration of postoperative catheterization until the PVR urine volume was less than 100 ml was 3.5(3-5) days in group A and 6(4-8.5) days in group B (P value=0.002), The rate of late postoperative complications including bladder dysfunction was 3.3% (Group A) and 31.25% (Group B) (P value 0.002). Conclusion:Our study results supported the feasibility of LNSRH technique with better functional outcome without compromising the oncologic safety of the procedure

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.

Stridor as the First Presentation of Metastatic Breast Cancer that Was Managed with Chemotherapy: a Case Report

Supraclavicular nodal metastases of breast cancer are rare and occur in about 8% of newly diagnosed cases. It is rarely discussed in the literature that breast cancer was metastasizing to higher levels of the cervical nodes. We report a case of metastatic breast cancer to the deep cervical lymph nodes that caused stridor due to compression of the recurrent laryngeal nerve which was diagnosed by indirect laryngoscopy. After full investigations, urgent chemotherapy was started and it showed a dramatic response with disappearance of the lymph node after two cycles with resolution of the stridor. This report also highlights the association of other metastatic sites with this higher level of neck nodal metastases of breast cancer.

Lateral Versus Anterior Approach Laparoscopic Splenectomy: A Randomized-controlled Study

Purpose of the Study: The study compares prospectively the hospital stay and postoperative complications of anterior (ALS) versus lateral (LLS) approach for laparoscopic splenectomy. Materials and Methods: Between September 2011 and April 2015, 94 patients with splenomegaly were referred to the surgical unit in the Oncology Center of Mansoura University, Egypt. Only 80 patients with splenomegaly <30 cm underwent an open-label randomized allocation into 2 equal parallel groups. Indications were hematological in 52 patients (65%) and malignant splenic conditions in 28 patients (35%). Two patients younger than 18 years, 4 patients with splenomegaly >30 cm, and 8 patients with associated surgical comorbidities were excluded. Three days’ hospital stay reduction with LLS was suggested with a power of 80% and P-value of 0.05. Results: The mean hospital stay was significantly shorter (P=0.001) after LLS. Laparoscopic splenectomy was completed in 68 patients (85%). Twelve patients (15%) required open splenectomy with no difference between groups. The operation time was significantly shorter in LLS (P=0.013). Blood loss (P=0.057) and blood transfusion (P=0.376) showed no difference between the two groups. The times until resumption of oral intake (P=0.019) and drain removal (P=0.011) were statistically shorter in LLS. Conclusions: LLS is more safe and feasible with shorter hospital stay compared with ALS.