Hosam Hamed

Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized study

BACKGROUND The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. METHODS Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. RESULTS One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. CONCLUSION Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS. GOV ID NCT02142517.

Impact of obesity on surgical outcomes post-pancreaticoduodenectomy: A case-control study

BACKGROUND Obesity is a growing worldwide epidemic. There is association between obesity and pancreatic cancer risk. However, the impact of obesity on the outcome of pancreatoduodenectomy (PD) is controversial. The aim of this study was to elucidate effect of obesity on surgical outcomes of PD. STUDY DESIGN A case-control study. PATIENT AND METHODS We retrospectively studied all patients who underwent PD in our center between January 2000 and June 2012. Patients were divided into two groups; Group A (patients with BMI <25) and Group B (patients with BMI > 25). Preoperative demographic data, intraoperative data, and postoperative details were collected. RESULTS Only 112/471 patients (25.9%) had BMI > 25. The median intraoperative blood loss was more in overweight patients (P = 0.06). The median surgical time in group B was significantly longer than that in group A (P = 0.003). The overall incidence of complications was higher in the overweight group (P = 0.001). The severity of complications was also higher in the overweight group (P = 0.0001). Postoperative pancreatic fistula (POPF) (P = 0.0001) and hospital mortality (P = 0.001) were significantly higher in overweight patients. Oral intake was significantly delayed in overweight patients in comparison to normal weight group (P = 0.02). Postoperative stay was significantly longer in overweight patients (P = 0.0001). CONCLUSION PD is associated with an increased risk of postoperative morbidity in overweight patient. Overweight patients must not be precluded from undergoing PD. However, operative techniques and pharmacological prophylaxis to decrease POPF should be considered in overweight patients.

Diagnosis and management of choledochal cyst: 20 years of single center experience

We report the first case series from Africa and the Middle East on choledochal cyst, a disease which shows significant geographical distribution with high incidence in the Asian population. In this study, the epidemiological data of the patients are presented and analyzed. Attention was paid to diagnostic imaging and its accuracy in the diagnosis and classification of choledochal cyst. Most cases of choledochal cyst disease have type I and IV-A cysts according to the Todani classification system, which support the etiological theories of choledochal cyst, especially Babbitts theory of the anomalous pancreaticobiliary duct junction, which are clearly stated. The difficulties and hazards of surgical management and methods used to avoid operative complications are clarified. Early and late postoperative complications are also included. This study should be followed by multicenter studies throughout Egypt to help assess the incidence of choledochal cysts in one of the largest populations in Africa and the Middle East.

Problem of living liver donation in the absence of deceased liver transplantation program: Mansoura experience

We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.

Hilar cholangiocarcinoma in cirrhotic liver: A case–control study

BACKGROUND Surgical resection is the only hope for patients with cholangiocarcinoma (CC). This study is designed to assess the impact of cirrhosis on the outcome of surgical management for CC. PATIENT AND METHODS We retrospectively studied all patients who underwent surgical resection for hilar CC. Group I (patients with cirrhotic liver) and Group II (patients with non-cirrhotic liver). Preoperative demographic data, intra-operative data, and postoperative details were collected. RESULTS Only 102/243 patients (41.9%) had cirrhotic liver. Caudate lobe resection was more frequently performed in the non-cirrhotic group (P = <0.001). There was no difference between both groups regarding intraoperative blood loss and the need for blood transfusion. The median postoperative stay was higher in the cirrhotic group (P = 0.063). The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group (P = <0.001). Cirrhosis was associated with significantly lower overall survival (P = <0.001). CONCLUSION Patients with concomitant liver cirrhosis and hilar CC should not be precluded from surgical resection and should be considered for resection at high volume centers with expertise available to manage liver cirrhosis. The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group.

Knowledge and Attitudes about Organ Donation among Medical Students in Egypt: A Questionnaire

Introduction: Organ transplantation (OT) is life-saving for patients with failing organs. Shortage of donor organs can be solved by raising the willingness of the population to donate organs. Health-care professionals have a fundamental role in raising the public awareness. Methods: This is a cross sectional descriptive study in which a specially designed self-administered questionnaire to assess knowledge and attitude towards organ donation (OD) was used to perform a survey on a representative sample of pre-medical students in a local high school whose major is biology science and medical students in Faculty of Medicine, Mansoura University, Egypt. Results: A total of 359 students completed the questionnaire. 36% of the students had good knowledge about OD; however, 11.7% of them had good knowledge about brainstem death. 66.3% of students found their information resources insufficient. 77.7% of participants didn’t know about the law regulating OD in Egypt. 37% of the students had positive attitude towards organ donation. The most frequent cause for organ donation refusal was lack of confidence in the health care system (31%). There is a significant relation between student knowledge and positive attitude towards OD (P=0.003). Students knowledge was significantly associated with seniority (P = 0.0001) and Christian religion (P=0.04). Conclusion: There is lack of sufficient knowledge about the legal aspect criteria and details of organ donation process which directly contributing in reducing the positive attitude among Egyptian medical students. In a religiously and culturally accepted background, educational curriculum must focus on the importance of OD in modern surgical practice. Awareness of regulating law and the concept of brainstem death is crucial for positive attitude from OD.

Hepatic venous outflow obstruction after living donor liver transplantation managed with ectopic placement of a foley catheter: A case report.

Highlights • Hepatic venous outflow obstruction is a rare serious complication after liver transplantation.• Hepatic venous outflow obstruction may result in graft loss and recipient death.• We report the use of the foley catheter to temporary fix the graft and correct the hepatic venous outflow obstruction.• It is a simple, cheap and safe device to correct the hepatic venous outflow obstruction.• It could be easily monitored and removed under Doppler US without any device related complications.

Hepatobiliary rhabdomyosarcoma mimicking choledochal cyst: Lessons learned

INTRODUCTION The differential diagnosis of hepatic cystic lesions is a challenging process especially in case of hepatic rhabdomyosarcoma (HRMS) presenting as hepatic cyst. PRESENTATION OF CASE We introduce our experience with a case of HRMS in a 3-year-old female patient who was misdiagnosed to have type IV-A choledochal cyst and definitive correct diagnosis was reached after the pathological and immunohistochemical examination of the surgically resected lesion. This case presentation is followed by important practical messages to hepatobiliary surgeons regarding HRMS. DISCUSSION HRMS is a rare pediatric tumor. Jaundice is the most common presentation of HRMS followed by abdominal pain and vomiting. Great effort is needed to differentiate the tumor from choledochal cyst and infectious hepatitis. Through evaluation using available imaging studies together with clinical anticipation is mandatory for establishing the correct diagnosis. CONCLUSION Differentiation of HRMs from choledochal cyst mandates through evaluation and clinical anticipation. HRMS should be suspected in any child with obstructive jaundice. Once diagnosis is established, multidisciplinary treatment is the best management strategy and it has proved better surgical outcome and long term survival.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity

AIM To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity. METHODS This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected. RESULTS The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP. CONCLUSION PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

Refractory complex gastrobroncho-cutaneous fistula after laparoscopic sleeve gastrectomy: a novel technique for endoscopic management

Refractory complex gastrobroncho-cutaneous fistula after laparoscopic sleeve gastrectomy: a novel technique for endoscopic management Emad Abdallah, M.D., Hosam Hamed, M.D.*, Mohamed Fikry, M.S. Surgical Department, Mansoura University, Mansoura, Egypt Gastrointestinal Surgical Center, Surgical Department, Mansoura University, Mansoura, Egypt Surgical Department, Mansoura University, Mansoura, Egypt Received February 16, 2016; accepted February 23, 2016