Omar Fathy

Lifestyle, occupational, and reproductive factors in relation to pancreatic cancer risk

Objectives: This study examined the epidemiology of pancreatic cancer in Egypt. Methods: We obtained detailed information on smoking, occupational, medical, and reproductive histories from 194 pancreatic cancer cases and 194 controls. Results: Compared with not smoking, smoking cigarettes alone or in conjunction with other smoking methods (eg, water pipe, cigar) was associated with an increased risk (odds ratio [OR], 4.5 and 7.8; 95% confidence interval [95% CI], 1.9-10.7 and 3.0-20.6, respectively). Passive smoking was also a significant risk factor (OR, 6.0; 95% CI, 2.4-14.8). The risk of pancreatic cancer was elevated among subjects exposed to pesticides (OR, 2.6; 95% CI, 0.97-7.2). A prior diagnosis of diabetes mellitus for a period of 10 years was associated with higher risk (OR, 5.4; 95% CI, 1.5-19.9). For women, having 7 or more live births and lactating for 144 months or longer were associated with a reduced risk (OR, 0.5 and 0.2; 95% CI, 0.2-1.3 and 0.1-0.9, respectively). No association was found between family history, allergy, or obesity and pancreatic cancer in Egypt. Conclusions: Multiple tobacco consumption methods, passive smoking, pesticide exposures, and diabetes are associated with an increased risk for pancreatic cancer. Prolonged lactation and increased parity are associated with a reduced risk for pancreatic cancer.

Serum Cadmium Levels in Pancreatic Cancer Patients from the East Nile Delta Region of Egypt

The northeast Nile Delta region exhibits a high incidence of early-onset pancreatic cancer. It is well documented that this region has one of the highest levels of pollution in Egypt. Epidemiologic studies have suggested that cadmium, a prevalent pollutant in the northeast Nile Delta region, plays a role in the development of pancreatic cancer. Objective: We aimed to assess serum cadmium levels as markers of exposure in pancreatic cancer patients and noncancer comparison subjects from the same region in Egypt. Design and Participants: We assessed serum cadmium levels of 31 newly diagnosed pancreatic cancer patients and 52 hospital comparison subjects from Mansoura, Egypt. Evaluation/Measurements: Serum cadmium levels were measured using a novel immunoassay procedure. Results: We found a significant difference between the mean serum cadmium levels in patients versus comparison subjects (mean ± SD, 11.1 ± 7.7 ng/mL vs. 7.1 ± 5.0 ng/mL, respectively; p = 0.012) but not in age, sex, residence, occupation, or smoking status. The odds ratio (OR) for pancreatic cancer risk was significant for serum cadmium level [OR = 1.12; 95% confidence interval (CI), 1.04–1.23; p = 0.0089] and farming (OR = 3.25; 95% CI, 1.03–11.64; p = 0.0475) but not for age, sex, residence, or smoking status. Conclusions: The results from this pilot study suggest that pancreatic cancer in the East Nile Delta region is significantly associated with high levels of serum cadmium and farming. Relevance to Clinical Practice/Public Health: Future studies should further investigate the etiologic relationship between cadmium exposure and pancreatic carcinogenesis in cadmium-exposed populations.

Distal splenorenal shunt for management of variceal bleeding in patients with schistosomal hepatic fibrosis

The distal splenorenal shunt was performed in 60 patients with schistosomal hepatic fibrosis in whom no evidence of cirrhosis was documented by preoperative needle and operative wedge biopsy. No patients have been lost to follow-up with a median of 37 months (range: 17-86). The results showed low operative mortality (1.7%), high patency rate (92.5%), and low recurrent variceal hemorrhage (6.7%). Thrombosed shunts were treated either by refashioning the shunt (1 patient) or splenectomy and gastric devascularization (2 patients). Initial hyperbilirubinemia and reduction in serum albumin were found in the early postoperative period, with persistent hyperbilirubinemia in 32% of the patients. The 5-year survival was 88%, with liver disease related mortality in only three patients. Clinical encephalopathy was detected in three patients (5.1%); only one of them was incapacitated. These data showed that: selective shunt (distal splenorenal shunt, DSRS) is an effective surgical procedure in the treatment of schistosomal variceal bleeding, shunt thrombosis is rare and can possible be corrected if detected early, schistosomal patients have a better survival and a lower incidence of encephalopathy after DSRS than that reported in cirrhotics, and liver biopsy should be performed for proper assessment of the schistosomal population especially in the geographic areas where the schistosoma parasite and viral hepatitis are endemic.

Selective shunt versus nonshunt surgery for management of both schistosomal and nonschistosomal variceal bleeders

This clinical study included 219 (Child A/B) consecutive variceal bleeders. Electively 123 had distal splenorenal shunt (DSRS) and 96 had splenectomy with gastroesophageal devascularization (S&GD). Liver pathology was documented in 73% of patients, with schistosomal fibrosis in 41% and nonalcoholic cirrhosis or mixed pattern (fibrosis and cirrhosis) in 59%. The surgical groups were similar before operation, with a mean follow-up of 82

Differing molecular pathology of pancreatic adenocarcinoma in Egyptian and United States patients

pM 13 and 78

Unusually High Rate of Young-Onset Pancreatic Cancer in the East Nile Delta Region of Egypt

pM 18 months, respectively (range, 60 to 120 months). The two pathologic populations were also similar before each and both procedures. The operative mortality rates were low, with incidences of 3.3% (DSRS) and 3.1% (S&GD). Rebleeding occurred significantly (p < 0.05) more frequently after S&GD (27%) compared to DSRS (5.7%). Sclerotherapy salvaged 65% of S&GD rebleeders. Encephalopathy developed significantly (p < 0.05) more after DSRS (18.7%) compared to S&GD (7.3%), with no significant difference among the current survivors. The difference in overall rebleeding and encephalopathy rates between both procedures was statistically related to patients with cirrhosis and mixed lesions (p < 0.05). Distal splenorenal shunt significantly reduced the endoscopie variceal size more than S&GD (p < 0.05). Prograde portal perfusion was documented in 94% of patients in each group, with a variable distinct pattern of portaprival collaterals in 91% (DSRS) and 65% (S&GD). The total population cumulative survival was similar with 80% for DSRS and 79% for S&GD (plus sclerosis in 23%), with hepatic cell failure the cause of death in 46% and 50%, respectively. However, in the schistosomal patients, survival was better improved after DSRS (90%) compared to S&GD (75%), with no difference among the cirrhotic and mixed group (DSRS 73%, S&GD 72%). In conclusion (1) both DSRS and S&GD have low operative mortality rates, (2) DSRS is superior to S&GD in the schistosomal patients, and (3) S&GD backed by endosclerosis for rebleeding is a good surgical alternative to selective shunt in the nonalcoholic cirrhotic and mixed population.

Caudate lobe resection with major hepatectomy for central cholangiocarcinoma: is it of value?

Variations in genetic mutations in pancreatic carcinoma between different populations have not been studied extensively, especially in developing countries where pancreatic cancer is rare. We studied the molecular pathology of 44 pancreatic carcinomas from patients residing in a heavily polluted region in the Nile River delta and compared the findings with tumors from 44 United States (US) patients. We evaluated K‐ras mutations in codon 12, p53 mutations in exons 5–8, and Gadd45a mutations in exons 1 and 4. Overall, rates of K‐ras, p53 and Gadd45 mutations were not statistically different in tumors of patients from Egypt and the US (67.4 vs. 63.4%; 27.3 vs. 36.4% and 9.1 vs. 4.5%, respectively). However, there were distinct differences in the specific types of K‐ras and p53 mutations between the 2 groups. In K‐ras, G → T transversion mutation was more frequent in the tumors from Egypt than from the US (58.6 vs. 26.9%), whereas G → C transversion was detected in 26.9% of US tumors but none from Egypt (p = 0.003). We also found a trend toward differences in the p53 exons in which mutations occurred, with higher frequency of exon 5 mutation and lower frequency of exon 6 mutation in Egyptian tumors. Logistic regression showed that K‐ras G → T transversion mutations and p53 exon 6 mutations were predicted by the country of residence of the patients. Our study identifies that there are differences in the types of mutations found in tumors from pancreatic carcinoma patients in Egypt and the US, and suggests that environmental factors may explain these differences.

Schistosomal versus nonschistosomal variceal bleeders. Do they respond differently to selective shunt (DSRS)

SummaryBackground. Pancreatic cancer is predominantly a disorder of the elderly population in the United States. In Egypt, the disease has traditionally been considered rare, and there has not been a previous publication on its population-based incidence or age distribution.Methods. We reviewed the records of 728 pancreatic cancer patients seen at the Gastrointestinal Surgery Center of Mansoura University in the East Nile Delta region of Egypt between 1995 and 2000. We computed population-based, age-specific, and age-adjusted incidence rates in this population and compared them with US incidence rates from the Epidemiology Surveillance and End Results (SEER) Program. We also analyzed clinical characteristics of the patients, as well as their surgical and medical management.Results. Approximately one-fourth of all patients were under age 50. The mean ages of patients who had undergone Whipple’s resection, other surgical procedures, and no surgical procedure were 52.9 ± 11.6, 54.11 ± 10.5, and 55.1 ± 14.1 yr, with no statistically significant differences. Age-adjusted incidence rates were higher in Egyptian patients than in US patients under age 65 (7.1/100,000 vs 3.3/100,000) but were much higher in US patients than in Egyptian patients over age 65 (6.6/100,000 vs 59.1/100,000). Clinical management did not differ between patients under and over age 50.Conclusion. The population in the East Nile Delta region of Egypt exhibits an unusually high rate of young-onset pancreatic cancer. Further studies to investigate the epidemiology of pancreatic cancer in this population may provide clues to its etiology.

Biliary complications in living donor right hepatectomy are affected by the method of bile duct division

BACKGROUND/AIMS The aim of this study was to evaluate the importance of concomitant caudate lobe resection in the course of major hepatectomy for hilar cholangiocarcinoma. METHODOLOGY During the period between January 1995 and December 2010, 159 patients were subjected to major hepatectomy with or without total caudate lobe resection at the Gastroenterology Centre, Mansoura University. These patients were divided in two groups: 1) a caudate lobe preservation (CLP) group (79 patients) and 2) a caudate lobe resection (CLR) group (80 patients). All patient data were retrospectively reviewed. RESULTS This study included 94 men and 65 women with a mean age of 53.5±0 years without operative mortality. No differences were observed between groups regarding operative time, blood loss or the development of any individual postoperative complication. There were 23 (28.8%) margin-positive resections in the CLR group and 49 (62%) margin-positive resections in the CLP group (p≤0.001). Recurrence was confirmed in 53 (67.1%) and in 41(51.3%) patients in the CLP and CLR groups, respectively (p=0.031). The median survival of the CLR group was 36 months with a 5-year survival rate of 28%, while the median survival of the CLP group was 22 months with a 5-year survival rate of 5% (p≤0.001). CONCLUSIONS Caudate lobe resection in combination with major hepatectomy did not affect operative or postoperative morbidity and mortality. However, it led to higher rates of margin-negative resections and significantly improved survival.

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

The distal splenorenal shunt (DSRS) was performed in 125 consecutive variceal bleeders. To date, no patients have been lost to follow-up (mean of 79 +/- 20 months). Liver pathology was documented in 85 patients: 45 patients had schistosomal hepatic fibrosis, 17 had nonalcoholic cirrhosis, and 23 had mixed pattern (hepatic fibrosis and cirrhosis). The preoperative data base for these three groups was matched (p greater than 0.05), with a mean follow-up of 79 +/- 20, 70 +/- 14, and 77 +/- 22 months for each population, respectively. The results showed low operative mortality (4.8%), high cumulative patency rate (94.8%) and low recurrent variceal hemorrhage (5.6%). The biochemical data showed significant increase in serum bilirubin (p less than 0.001) and aspartate transaminase (AST) (p less than 0.05) in the nonschistosomal patients. Chronic hyperbilirubinemia was found in 33% of the schistosomal group. Prograde portal perfusion was detected in 94% of the patients, with development of collaterals in 91%. The angiographic pattern of these collaterals was 50% pancreatic, 45% gastric, and 26% colosplenic. Patients with mixed liver disease had a high incidence of Grade III portal perfusion (57%) and more common pancreatic and gastric collaterals (71%). The cumulative survival for all patients was 74.1%, with hepatic cell failure being the leading cause of death (13 patients, 50% of all deaths). The schistosomal patients had a 91.6% incidence, whereas the cirrhotic and mixed groups had survival rates of 75.6% and 65.2%, respectively. Also, of a 15% total incidence of encephalopathy, 4.4% was related to the schistosomal patients, 23.5% to the cirrhotics, and 21.7% to the mixed population. Statistically, the survival rate was significantly better (p less than 0.05) and encephalopathy was significantly lower (p less than 0.05) in the schistosomal population. In conclusion, this data shows that: 1) DSRS has a high patency rate and a low variceal hemorrhage recurrence rate; 2) it maintains some degree of portal perfusion in patients with different nonalcoholic liver diseases, despite development of collaterals; and 3) the schistosomal patients have a better survival rate, with a low incidence of encephalopathy after DSRS, compared with the cirrhotic and mixed populations.