Mahmoud Sakr

Assessment of parathyroid autotransplantation for preservation of parathyroid function after total thyroidectomy

Hypoparathyroidism with permanent hypocalcemia is a well‐recognized complication after thyroid surgery.

Review of tumoral calcinosis: A rare clinico-pathological entity.

Tumoral calcinosis (TC) has long been a controversial clinico-pathological entity. Its pathogenesis and genetic background have been gradually unravelled since its first description in 1943. According to the presence or absence of an underlying calcifying disease process, TC has been divided into primary and secondary varieties. Two subtypes of the primary variety exist; a hyper-phosphatemic type with familial basis represented by mutations in GalNAc transferase 3 gene (GALNT3), KLOTHO or Fibroblast growth factor 23 (FGF23) genes, and a normo-phosphatemic type with growing evidence of underlying familial base represented by mutation in SAMD9 gene. The secondary variety is mainly associated with chronic renal failure and the resulting secondary or tertiary hyperparathyroidism. Diagnosis of TC relies on typical radiographic features (on plain radiographs and computed tomography) and the biochemical profile. Magnetic resonance imaging can be done in difficult cases, and scintigraphy reflects the disease activity. Treatment is mainly surgical for the primary variety; however, a stage-oriented conservative approach using phosphate binders, phosphate restricted diets and acetazolamide should be considered before the surgical approach is pursued due to the high rate of recurrences and complications after surgical intervention. Medical treatment is the mainstay for treatment of the secondary variety, with failure warranting subtotal or total parathyroidectomy. Surgical intervention in these patients should be kept as a last resort.

LigaSure Hemorrhoidectomy Versus Stapled Hemorrhoidopexy: A Prospective, Randomized Clinical Trial

PURPOSE This study was designed to compare the outcome of LigaSure hemorrhoidectomy and stapled hemorrhoidopexy for prolapsed hemorrhoids. METHODS Consecutive patients with grade III or IV hemorrhoids were randomly assigned to undergo either LigaSure hemorrhoidectomy or stapled hemorrhoidopexy. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, number of parenteral analgesic injections, duration of hospital stay, and time to return to work were all prospectively collected. Postoperative complications and recurrence of prolapse were also recorded. Patients were regularly followed for a total period of 12 months. RESULTS A total of 68 patients completed the study (34 per group). Patient demographic and clinical characteristics were similar in the 2 groups. No significant differences between LigaSure hemorrhoidectomy and stapled hemorrhoidopexy were observed in mean operating time, postoperative pain score, number of parenteral analgesic injections, duration of hospital stay, or time to return to work. The groups were also similar regarding postoperative complications, except that at 4 weeks postoperatively, residual prolapse was observed in 8 patients (23.5%) in the stapled hemorrhoidopexy group vs. 2 patients (5.9%) in the LigaSure group (P = .040). Rate of recurrence of prolapse at 1 year was higher with stapled hemorrhoidopexy (4 patients, 11.8%) than with the LigaSure procedure (1 patient, 2.9%), but the difference was not significant (P = .163). CONCLUSIONS LigaSure hemorrhoidectomy and stapled hemorrhoidopexy yield comparable good results, with a short operative time and minimal side effects in the treatment of grade III and IV hemorrhoids, but with a lower rate of residual prolapse for the LigaSure procedure. Both procedures offer low levels of postoperative pain and therefore are excellent therapeutic options for prolapsed grade III and IV hemorrhoids. A larger controlled study is needed to reach solid conclusions regarding risk of postoperative recurrence of hemorrhoidal prolapse.

Axially vascularised mandibular constructs: Is it time for a clinical trial?

Applying regenerative therapies in the field of cranio-maxillofacial reconstruction has now become a daily practice. However, regeneration of challenging or irradiated bone defects following head and neck cancer is still far beyond clinical application. As the key factor for sound regeneration is the development of an adequate vascular supply for the construct, the current modalities using extrinsic vascularization are incapable of regenerating such complex defects. Our group has recently introduced the intrinsic axial vascularization technique to regenerate mandibular defects using the arteriovenous loop (AVL). The technique has shown promising results in terms of efficient vascularization and bone regeneration at the preclinical level. In this article, we have conducted a narrative literature review about using the AVL to vascularize tissue-engineering constructs at the preclinical level. We have also conducted a systematic literature review about applying the technique of axial vascularization in the field of craniofacial regeneration. The versatility of the technique and the possible challenges are discussed, and a suggested protocol for the first clinical trial applying the AVL technique for mandibular reconstruction is also presented.

Rapid hepatic perfusion decellularization: technique and critique.

Organ shortage facing the increasing success of liver transplantation has provoked research into the utilization of animal organs for clinical transplantation. The technique of whole‐organ decellularization aims at the removal of the antigenic cellular content, thus evading the immune rejection cascade and the production of complex three‐dimensional extracellular matrices of the entire organs with preservation of their intrinsic vascular networks rendering them transplantable. The aim of this study was the production of decellularized rabbit liver matrices by applying a simple, rapid perfusion decellularization technique and their characterization (both qualitatively and quantitatively).

Pathogenesis of varices in schistosomal portal hypertension

Patients with schistosomiasis and portal hypertension have significantly lower levels of hydroxyproline in their saphenous veins and anterior rectus sheaths than do individuals without schistosomal hepatic fibrosis. The stomach of patients with schistosomal portal hypertension demonstrates an increased number of lymphatics by lymphangiography. The disrupted lymph node architecture in these patients could be partially responsible for dilation, tortuosity, and retrograde lymph flow in the gastric lymphatics. These histological and lymphangiographic findings could be attributed to the effect of venous and lymphatic hypertension. A postmortem histological examination of the esophagus of patients with decompensated schistosomal portal hypertension revealed edema of the entire esophageal wall with lymphatic dilation and tortuosity. Based upon these data, we suggest that the varices that develop in patients with schistosomal portal hypertension occur as a consequence of an increased portal venous pressure together with acquired lymphangectasia as well as an intrinsic weakness of the walls of the portosystemic venous channels.

Review of Heterotopic Thyroid Autotransplantation

Total thyroidectomy is increasingly accepted for the management of bilateral benign thyroid disorders. Postoperatively, patients require lifelong levothyroxine replacement therapy to avoid postoperative hypothyroidism, which besides the burden of compliance, has been proven to be associated with several long-term side effects. Heterotopic thyroid autotransplantation was proposed several decades ago to avoid the need for life-long postoperative replacement therapy with maintaining the autoregulatory mechanism of thyroxin production inside the body according to its needs. Available data regarding this topic in literature is relatively poor. Before applying thyroid autotransplantation on humans, several studies have been done on animals, where the autologous transplantations were found to be successful in almost all the cases, proved by follow up postoperative 8-week measurements of thyroid hormones and histopathological examination of the removed autografts. Regarding the clinical application, few trials have been done using cryopreserved in vivo, in vitro or immediately autotransplanted thyroid autografts. Satisfactory results were obtained, however, the number of these studies and the number of patients per each study was very low. Besides the study methodologies were not so consistent.

Hurthle Cell Lesion: Controversies, Challenges, and Debates

Hurthle cell lesion is one of the most questionable clinico-pathological entities in most of its aspects. Literature has used the terms oncocytic, oxyphilic, Hurthle, and Ashkanazy interchangeably; what does each term denote? Who first described these cells? What is the cell of origin? How much Hurthle cells should be present to define the lesion as Hurthle cell one? Is it possible to differentiate hyperplastic from neoplastic and benign from malignant Hurthle cell lesion on a non-histopathologic ground? Does it belong to follicular or to papillary neoplasms or should it be classified separately? Can we anticipate its clinical behavior or predict its outcome? How can we manage? We will try to answer these questions in light of the ongoing relevant arguments with the aim of resolving some uncertainties and suggesting how to solve others.

Heterotopic thyroid autotransplantation: A preliminary clinical study

Thyroid autotransplantation offers an attractive alternative to subtotal thyroidectomy and replacement therapy. However, it has not been sufficiently clinically investigated.

Independent predisposing factors for subcutaneous and deep wound collection after total thyroidectomy, a prospective cohort study

Background The literature contains diverse and sometimes contradicting results about wound seroma following thyroidectomy. This is probably due to the subjective clinical estimation of seroma, or due to failure to differentiate between the occurrence of subcutaneous (SC) and deep wound collections. This work aimed at objectively investigating the factors affecting subcutaneous and deep wound seroma after thyroidectomy. Methods The relation between various operative and clinico-pathological factors and the collection formation was prospectively analyzed in a cohort of 100 patients after conventional thyroidectomy. Wound seroma was assessed clinically and via high-resolution ultrasonography at 24 h, 48 h and two weeks postoperatively. Sonographically detected collections were expressed as SC and/or deep wound collections according to the relation to strap muscles. Results Operative duration was the only independent factor significantly affecting the incidence of clinical seroma. Older patients (>40ys) showed significantly larger volumes of early SC collections. Early postoperative pain was significantly related to drain insertion, to the occurrence of clinical seroma and to the volume of SC collections. Sonographically, suction drains and shorter operative durations resulted in significantly less amount of deep collections. Suction drains did not result in less amount of SC collections or in a lower incidence of clinical seroma. Conclusions Operative duration is the only independent factor significantly related to clinically-detected postoperative seroma with its subsequent postoperative pain. Especially in elderly patients, a flapless technique would be recommended as these patients developed larger volumes of SC collections with subsequent higher pain scores, even if seroma was not clinically detected.