Khaled M. El-Asmar

Topical mitomycin C application is effective in management of localized caustic esophageal stricture: A double-blinded, randomized, placebo-controlled trial

BACKGROUND Frequent sessions of endoscopic dilatation are usually required in the management of benign esophageal strictures, especially caustic induced ones. Topical mitomycin C (MMC) has been recently used in the management of resistant strictures. This study evaluated the efficacy of MMC application in prevention of stricture recurrence after endoscopic dilatation. PATIENTS AND METHODS This double-blind, randomized, placebo-controlled trial included forty patients with caustic esophageal strictures dating from January 2008 to October 2010. Patients were randomized into 2 groups to undergo endoscopic dilatation with application of either MMC versus placebo on stricture site. Regular follow up and re-evaluation were done after 6 months of management. The number of dilatation sessions needed for resolution of dysphagia in each group was our primary outcome. RESULTS During the specified follow up period, 80 % of strictures in the MMC group got completely resolved compared to only 35% in the placebo group. The mean number of dilatation sessions needed in the MMC group was n = 3.85 ± 2.08 compared to n = 6.9 ± 2.12 in the placebo group which was statistically significant (p < 0.001). CONCLUSION Mitomycin C application significantly reduced the number of dilatation sessions needed to alleviate dysphagia in patients with caustic esophageal strictures.

Topical mitomycin C can effectively alleviate dysphagia in children with long-segment caustic esophageal strictures.

Caustic ingestion in children and the resulting long esophageal strictures are usually difficult to be managed, and eventually, esophageal replacement was required for cases refractory to frequent dilatation sessions. Topical mitomycin C (MMC) application has been used recently to improve the results of endoscopic dilatation for short esophageal strictures. The study aims to assess the role of MMC application in management of long-segment caustic esophageal strictures. From January 2009 to June December 2013, patients presented with long caustic esophageal stricture (>3 cm in length) were included in this study and subjected to topical MMC application after endoscopic esophageal dilatation on multiple sessions. Regular follow-up and re-evaluation were done. A dysphagia score was used for close follow-up clinically; verification was done radiologically and endoscopically. During the specified follow-up period, 21 patients with long caustic esophageal stricture were subjected to topical MMC application sessions. Clinical, radiological, and endoscopic resolution of strictures occurred in 18 patients (85.7% cure rate). Number of dilatation sessions to achieve resolution of dysphagia was (n = 14.3 ± 5.7) with application of mitomycin two to six times. There was no recurrence in short- and mid-term follow-up. No complications were encountered related to topical MMC application. MMC is a promising agent in management of long-segment caustic esophageal strictures. Long-term follow-up is needed to prove its efficacy and to evaluate potential long-term side-effects of MMC application.

Topical Mitomycin C application for esophageal stricture: Safe, precise, and novel endoscopic technique

PURPOSE The first line of management of benign esophageal stricture is endoscopic dilatation; however, multiple sessions are usually indicated especially in resistant cases. Topical Mitomycin C (MCC) application is a new adjuvant treatment in the management of esophageal stricture with promising results in different case series. Several techniques have been reported for application; nevertheless, the ideal technique has not been described yet. MATERIAL AND METHODS In this series we have devised a new technique using both the flexible and the rigid endoscope and a specially designed Nelaton catheter. RESULTS This technique was applied in 38 sessions for 16 caustic esophageal strictures with technical success in all cases. No procedure-related complications were observed in this series. CONCLUSION This novel technique is feasible and effective and can be considered as standard for topical MMC application on esophageal stricture.

Simple antireflux technique for the cologastric anastomosis: complementary step in retrosternal colon interposition procedure.

Gastrocolic reflux is a troublesome symptom causing repeated aspiration or chocking in patients underwent retrosternal colon interposition. Various techniques were described to avoid such complication, however, they entail complicated technique that may jeopardize the viability of the graft or cause obstructing symptoms. A simple antireflux procedure is described here alleviating this problem. Over the last 7 years, 87 patients had gastrocolic antireflux procedure for cologastric anastomosis; 75 patients as a primary procedure (group 1) and 12 patients as a secondary procedure treating symptomatic reflux (group 2). The technique entails the creation of cologastric angle after finishing the cologastric anastomosis by applying three stitches between the colon and the stomach, thus tucking the colon to the stomach for 3-4 cm. Gastrocolic reflux was evaluated clinically and radiologically 3 months postoperatively. In group 1, three cases (4%) suffered symptomatic gastrocolic reflux, and seven cases (9.3%) had radiological asymptomatic mild reflux, while all patients in group 2 had complete alleviation of their symptoms with gastrogram showing no reflux. Gastrocolic reflux can be treated simply by creation of cologastric angle; however, controlled trial is needed to confirm its effectiveness in comparison to other described techniques.

Gastrografin in the management of adhesive small bowel obstruction in children: a pilot study

Background/purposeAdhesive small bowel obstruction (ASBO) is a common emergency problem in children with previous abdominal surgery. Management protocols usually start with a conservative approach that may be successful in some cases, whereas in others it will end eventually by laparotomy with its associated morbidity and mortality. Our aim was to assess the role of water-soluble contrast, gastrografin, in the conservative management of ASBO. Patients and methodsDuring the period January 2009 to July 2010, 33 patients with ASBO were presented at the Pediatric Surgery Unit at the Ain Shams University Hospitals. Patients who failed to improve after 48 h of conservative management in the absence of signs of strangulation were subjected to gastrografin administration. Patients were evaluated clinically and radiologically to determine the resolution of the adhesive attack, with estimation of hospital stay time. ResultsAn oral administration of gastrografin successfully completed the conservative management in eight of 12 patients (66.6%), thus avoiding surgery and subsequently reducing hospital stay. ConclusionGastrografin may have a valuable role in the management of ASBO, whether diagnostic or therapeutic, but a randomized controlled trial is needed to prove its effectiveness in reducing surgical intervention rate and hospital stay time.

Colonic Atresia: Association with Other Anomalies.

Background: Colonic atresia (CA) is a rare form of congenital intestinal atresia. Although CA may be isolated, it is more commonly reported in literature in association with other congenital anomalies. Materials and Methods: This study is a review of prospectively collected data of all the patients with colonic atresia presented to our center (Ain Shams University) during 2008 to 2016. Results: Twelve patients were enrolled in this study. The atresia was of type I in one case, type II in four cases, type IIIa in six cases, type IV in one case. These cases accounted for 4.9 % of intestinal atresias managed in our center during the same period. Five cases were isolated CA, while the other seven cases had associated abdominal congenital anomalies (exomphalos, Hirschsprungs disease, imperforate anus, closing gastroschisis, colonic duplication, and multiple small bowel atresia in two cases). The management in ten cases was by staged procedure with creation of a temporary stoma initially, while primary anastomosis was established in two cases. We had two cases with delayed presentations, one missed diagnosis, and three mortalities in this series. Conclusions: The low incidence of CA may result in delay in the diagnosis and management. Hirschsprungs disease should be excluded in every case of colonic atresia. Early diagnosis and proper surgical management is essential for good prognosis.

Mitomycin C application in resistant caustic esophageal stricture

Background/purposeCaustic esophageal strictures still represent a catastrophic problem in children of our country. Management protocol is usually started by regular esophageal dilatation in which multiple sessions may be needed until the resolution of dysphagia; however, in many cases endoscopic dilatation fails and therefore esophageal replacement is eventually required. Our aim is to assess the role of mitomycin C application in the management of caustic esophageal stricture refractory to regular endoscopic dilatation. Patients and methodsPatients with resistant caustic esophageal stricture were subjected to topical mitomycin C application on stricture site after endoscopic dilatation. Patients were followed up clinically using validated dysphagia score to assess the improvement of dysphagia, radiologically by contrast esophagogram and endoscopically to confirm resolution of the stricture. Results were analyzed and compared with results of a control group managed at the institution by a regular dilatation protocol. ResultsDuring the period January 2008 to June 2010, 12 patients with resistant caustic esophageal stricture were followed at our unit of whom six had a short esophageal stricture (<3 cm) and six had a long stricture (>3 cm). Topical mitomycin C application resulted in clinical and radiological resolution of dysphagia and strictures in 83% and 66% respectively, compared with 44 (eight out of 18 patients with short stricture) and 25% (two out of eight patients with long stricture) in the control group. ConclusionMitomycin C application can markedly improve the outcome of patients with caustic esophageal stricture, reducing the number of required sessions for endoscopic dilatation. However, double-blinded randomized controlled trial is needed to prove its effectiveness.

Comparison between the bone cutter with thermal cautery, Gomco, and Plastibell for circumcision in neonates and infants: a prospective randomized trial

Background Circumcision is the most common surgical procedure performed for a male newborn. This trial aimed to compare between three commonly used techniques for male circumcision in our institute. Patients and methods From January 2014 to January 2015, 150 babies were randomized into three groups according to the circumcision technique: babies circumcised using the bone-cutter forceps with thermal cautery (group I), Gomco clamp (group II), and the Plastibell device (group III). Intraoperative details, postoperative pain and complications, cosmetic outcome, and parent satisfaction were recorded. Results Operative time was significantly shorter for group I (P<0.001). Postoperative dressing was needed in 50% of infants in group II compared with 12% in group I. Analgesic consumption was significantly lower in group I (P<0.001). No significant differences were found between the three groups as regards the peer assessment score for the final cosmetic outcome. Parent satisfaction was significantly higher in groups I and II (P=0.023). Infection was reported only in the Plastibell device group, and 10% had device-related complications. Conclusion The thermal cautery with bone-cutter technique proved superiority in hemostasis, operative time, and parent satisfaction, with less pain in the postoperative period. All three techniques had comparable final cosmetic outcome.

Surgical management of corrosive-induced gastric injury in children: 10 years' experience

AIM The purpose of this study was to report surgical management and outcome of corrosive-induced gastric injuries in children at our institute over the last decade. PATIENTS & METHOD Medical records of patients admitted for corrosive-induced gastric injury at the Pediatric Surgery Department of Ain Shams University between January 2007 and January 2017 were retrospectively reviewed. RESULTS Twenty six cases (17 boys and 9 girls) were enrolled. Mean age was 3.61±1.29. Ingested agent was acid in all the patients. Main presenting symptom was gastric output obstruction in 22 cases. The interval between corrosive ingestion and presentation ranged from one to 135days (mean=43.9±34). Surgical procedure included total gastrectomy (n=2), partial gastrectomy (n=2), augmentation gastroplasty (n=1), Billroth I (n=2), antrectomy (n=2), antroplasty (n=3), gastrojejunostomy (n=2), Heineke-Mikulicz pyloroplasty (n=9), Finney pyloroplasty (n=5), and feeding jejunostomy (n=4). Anastomotic stricture requiring a second operation developed in one patient. There were three mortalities related to the associated esophageal strictures. The mean follow-up period is 3.5years. All patients are free of symptoms and gained adequate weight. CONCLUSION Surgery is the mainstay of management for corrosive-induced gastric injuries with good long-term results. Surgical procedure should be tailored according to the patients general condition and extent of gastric injury. LEVEL OF EVIDENCE This is a case series with no comparison group (level IV).

One-stage transanal Swenson procedure for rectosigmoid Hirschsprung’s disease in infants and children

ObjectiveThis study aimed to present the outcome of transanal one-stage Swenson pull-through procedure in the management of rectosigmoid Hirschsprung’s disease (HD). BackgroundHD is a common cause of intestinal obstruction in pediatric age. Several pull-through procedures have been used to treat this pathology. Patients and methodsBetween June 2008 and June 2015, 84 children with biopsy-proven HD underwent transanal one-stage Swenson pull-through procedure. Intraoperative details, postoperative complications, and bowel habits were recorded. Follow-up period ranged from 6 to 42 months. ResultsThe age at the time of surgery ranged from 3 months to 2 years. The length of the resected aganglionic segment ranged from 12 to 34 cm. The operating time ranged from 72 to 180 min. Postoperative hospital stay ranged from 3 to 6 days. There were no anastomotic leaks, no perianal infection, or postoperative bowel obstruction. Twelve patients (14.28%) developed postoperative enterocolitis. Six patients (7.14%) required a posterior internal sphincter myectomy despite repeated dilatations. All patients had less than four times bowel motions per day, 3 months after surgery. No voiding disturbances were encountered at the end of the follow-up period and none of the patients complained of recurrent constipation. Six patients developed perianal dermatitis, which was treated conservatively within 3 months after surgery. Anastomotic circumference could not be felt at digital examination in 78 patients 3 months after surgery. ConclusionOne-stage transanal Swenson pull-through procedure is a safe alternative and simpler procedure for rectosigmoid HD with low morbidities and accepted outcome as regards postoperative bowel habits.