Wael Khafagy

Early oral feeding in patients undergoing elective colonic anastomosis

BACKGROUND This study assesses the safety outcome of early oral feeding and reports on the factors affecting early postoperative feeding after colorectal procedures. PATIENTS AND METHODS Between June 2005 and April 2008, 120 consecutive patients underwent elective colonic anastomosis and were then randomized into two groups. The early feeding group began fluids on the first postoperative day while the regular feeding group was managed in the traditional way - nothing by mouth until the resolution of ileus. RESULTS The majority of patients (75%) tolerated the early feeding. The times to first passage of flatus (3.3+/-0.9 days vs 4.2+/-1.2 days) and stool (4.1+/-1.2 days vs 4.9+/-1.2 days) were significantly quicker in group 1. Hospital stay was also significantly shorter in the early feeding group (6.2+/-0.2 days vs 6.9+/-0.5 days). Operative time and amount of blood loss had an impact on the tolerability of early feeding while age, gender, type of operation and previous abdominal operation had no such impact. CONCLUSION Early oral feeding after colorectal surgery is safe and tolerated by the majority of patients. Operative time and amount of blood loss do, however, have an impact on the tolerability of early feeding.

Treatment of anal fistulas by partial rectal wall advancement flap or mucosal advancement flap: A prospective randomized study

BACKGROUND High transphincteric perianal fistula represents a technical challenge for surgical management. We compared the effects of partial rectal wall advancement flap versus the mucosal advancement flap in the treatment of high transphincteric perianal fistula in a randomized study in patients with anal fistula. PATIENTS AND METHOD Consecutive patients treated for transphincteric anal fistula at our institution were evaluated for inclusion. Participants were randomly allocated to receive Group I: Fistulectomy, closure of internal sphincter and rectal advancement flap includes mucosa, submucosa, and circular muscle layer sutured 1 cm below the level of internal opening or Group II: The same as group one but the flap includes only mucosa and submucosa. Study variables included fistula closure rate, continence, morbidity, postoperative pain, hospital stay and quality of life. RESULTS Forty patients with high transphincteric perianal fistula were randomized and completed the study. Operative time was 31.6 +/- 6.8 min in group I, and 29.4 +/- 4.7 min in group II (P = 0.783). Hospital stay was significantly more in group 2 (96.35 +/- 9.5 vs. 105.8 +/- 13.23) (P = 0.014) Immediate postoperative complications, occurred in one patients (5%) exposed to disruption in group I and 6 patients (30%) in group II. Recurrence occurred in 2 patients (10%) in the group I and 8 patients (40%) in group II. Two patients (10%) in group I developed incontinence for flatus and no patients in the group II develop such complication. CONCLUSION Partial thickness advancement flap is better than mucosal advancement flap.

Colorectal Cancer in Egypt – Does it Differ?

Colorectal cancer is a disease of the elderly, and affects the younger population with an incidence of 2 to 6%. An increasing number of young colorectal carcinoma patients attending at Mansoura University Hospital, Mansoura, Egypt, was noted.This report represents our data of the last 5 years, and compares these results with those of other countries and those previously reported from Egypt.Data were collected retrospectively from the patient records of 400 consecutive patients who had colorectal cancer form January 1994 to March 1999 at Mansoura University Hospital. The maximum incidence was seen in the 5th and 6th decades (mean age was 45 years). A total of 29% of patients were younger than 30 years of age and 26% of them above the age of 60 years. The rectum was the most common site involved (68% of patients), followed by the sigmoid (colon/rectal ratio was 4 : 8.5). Two percent of cases were Dukes A Stage, 26% Dukes B, 31% Dukes C, and 41% Dukes D. The percentage of patients who underwent potentially curative resection was 66% (263 patients).Colorectal carcinoma in Egypt shares the epidemiological characteristics of developing countries which are higher incidence in younger patients and carcinoma of the rectum predominatesZusammenfassungDas kolorektale Karzinom ist eine Erkrankung älterer Menschen und kommt bei Jüngeren mit einer Inzidenz von 2 bis 6% vor. Im Mansoura University Hospital, Mansoura, Ägypten, konnte jedoch eine steigende Zahl von jüngeren Patienten mit kolorektalen Karzinomen beobachtet werden.Dieser Bericht stellt die Daten der letzten fünf Jahre vor und vergleicht die Ergebnisse mit denen anderer Länder und früherer Berichte aus Ägypten.Die Daten wurden retrospektiv aus den Unterlagen von 400 konsekutiven Patienten gesammelt, die im Mansoura University Hospital zwischen Januar 1994 und März 1999 an einem kolorektalen Karzinom litten. Die größte Häufigkeit trat in der fünften und sechsten Dekade auf (Durchschnittsalter 45 Jahre). Insgesamt 29% der Patienten waren jünger als 30 Jahre und 26% älter als 60 Jahre. Das Rektum war am häufigsten betroffen (68% der Patienten), gefolgt vom Sigmoid (Verhältnis Kolon : Rektum 4 : 8,5). In 2% der Fä,lle handelte es sich um das Stadium Dukes A, in 26% um Dukes B, in 31% um Dukes C und in 41% um Dukes D. 66% (263) der Patienten konnten potentiell kurativ reseziert werden.Das kolorektale Karzinom in Ägypten teilt die epidemiologischen Chrakteristika von Entwickllungslä,ndern mit einer höheren Inzidenz bei jüngeren Patienten und einem Ü,berwiegen der Rektumkarzinome.

Potential utility of antineoplaston A-10 levels in breast cancer

Antineoplastons, first described by Burzynski, are naturally occurring peptides and amino acid derivatives, which control neoplastic growth. Antineoplaston A-10 (3-phenylacetyl amino-2, 6-pepridinedione) is the first chemically identified antineoplaston. Here we describe the potential utility of antineoplaston A-10 as a predictive test for breast cancer. Antineoplaston A-10 level was measured in the urine of 31 breast cancer patients and 17 normal women using high performance thin layer chromatography (HPTLC). Significantly lower antineoplaston A-10 levels were detected among patients with breast cancer with a P value <0.001. These data suggest a strong inverse association of urinary antineoplaston A-10 level with breast cancer. Such finding was the stimulus for further investigations of antineoplaston A-10 levels in some benign as well as other malignant diseases to determine the utility of this approach as a predictive test for women who are at risk of developing breast cancer.

Enteropathogenic Escherichia coli (EPEC): Does it have a role in colorectal tumourigenesis? A Prospective Cohort Study

BACKGROUND Despite the characterization of many aetiologic genetic changes. The specific causative factors in the development of sporadic colorectal cancer remain unclear. This study was performed to detect the possible role of Enteropathogenic Escherichia coli (EPEC) in developing colorectal carcinoma. PATIENTS AND METHOD Fresh biopsy specimens have been obtained from the colonic mucosa overlying the colorectal cancer as well as from the colon of the healthy controls. Culture, genotyping and virulence of EPEC were done using (nutrient broth culture, and PCR). Strains biochemically identified as Escherichia coli were selected from the surface of a MacConkeys plate and were serogrouped by slide agglutination tests. RESULTS From January 2011 to June 2014, 213 colorectal cancer patients (Group 1) and 248 healthy controls (Group 2) were prospectively enrolled in this study. EPEC was positive in 108 (50.7%) in group 1 and 51 (20.6%) in group 2 (P = 0.0001). A significant difference between both groups was observed regarding serotyping, genotyping (eae gene) and virulence category (P = 0.0001). A significant difference between the 2 subgroups of colorectal cancer cases was observed regarding genotyping (eae, bfb genes) and virulence category. CONCLUSION The incidence EPEC was higher significantly in patients with colorectal cancer. E. coli in patients with colorectal cancer significantly differed serotypically and genotypically from the E. coli in normal population. E. coli colonization of the colonic mucosa may be a cause colorectal cancer.

Indications for and outcome of primary repair compared with faecal diversion in the management of traumatic colon injury

Injuries of the colon are a serious sequel of abdominal trauma owing to the associated morbidity and mortality. This study aims to assess postoperative outcome and complications of faecal diversion and primary repair of colon injuries when applied according to established guidelines for the management of colon injuries.

Ultrastaging of Rectal Cancer Based on Identification of Micrometastases in Sentinel Lymph Node

Background and Purpose:Almost one third of patients with node-negative rectal carcinoma develop systemic disease. This implies that these patients have occult disease that is inadequately treated by surgery alone. In this study sentinel lymph node (SLN) mapping and a focused pathologic examination were combined to detect occult nodal metastases in rectal carcinoma.Patients and Methods:Since 1999, SLN mapping has been performed in 53 consecutive patients undergoing surgery for rectal carcinoma. Peritumoral injection of 0.5–1.0 ml of patent blue dye was performed to demonstrate the SLNs. All lymph nodes in the resected specimen were examined by routine hematoxylin-eosin (HE) staining. In addition, a focused examination of multiple sections of the negatively stained HE lymph node was performed using anti-carcinoembryonic antigen and monoclonal anti-cytokeratin.Results:Overall, lymphatic mapping was successful in 47 patients (88.7%). The number of patients with negative SLN and positive non-SLN amounted to four (skip lesion), two of them detected by HE staining and the others by immunostaining. Sensitivity was 81.6%, specificity 80%, and negative predictive value 63.2%. Negative HE staining and positive immunostaining were observed in 13 of 28 patients (stage B; 46%), nine SLN and four non-SLN. SLN detection proved to be successful when there was no evident lymph node involvement. Focused examination of the SLN identified seven cases (17.5%) of additional upstaging disease for stage pT1–3 N0 M0 tumor.Conclusion:Upstaging by combination of immunostaining and SLN mapping may have important implications for adjuvant treatment in future protocols.ZusammenfassungHintergrund und Fragestellung:Knapp ein Drittel aller Patienten mit nodal-negativen Rektumkarzinomen entwickelt eine systemische Tumorerkrankung. Dies bedeutet, dass diese Patienten ein okkultes Leiden haben, das durch die Operation allein nicht adäquat zu behandeln ist. In dieser Studie wurden das Sentinel Lymph Node (SLN) Mapping und eine darauf abgestimmte pathologische Untersuchung kombiniert, um okkulte Lymphknotenmetastasen eines Rektumkarzinoms zu entdecken.Patienten und Methodik:Seit 1999 wurde das SLN-Mapping bei 53 konsekutiven Patienten angewandt, die sich einer Operation wegen eines Rektumkarzinoms unterzogen. Um SLN nachzuweisen, wurde eine peritumoröse Injektion von 0.5–1.0 ml Patentblau verabreicht. Alle Lymphknoten im Resektat wurden mittels routinemäßiger Hämatoxylin-Eosin-(HE)-Färbung untersucht. Zusätzlich wurde eine gezielte Untersuchung verschiedener Teile des negativ-gefärbten HE-Lymphknotens durchgeführt, bei der ein anticarcinoembryonales Antigen und monoklonales Anticytokeratin eingesetzt wurden.Ergebnisse:Insgesamt war ein Lymphknoten-Mapping bei 47 Patienten (88.7%) erfolgreich. Die Anzahl von Patienten mit negativem SLN und positivem non-SLN belief sich auf vier (übersprungene Läsionen), zwei davon wurden von HE-Färbung, die anderen durch weitere Immunfärbungen entdeckt. Die Sensitivität war 81.6%, die Spezifität 80%, und der negative Vorhersagewert war 63.2%. Negative HE-Färbung und positive Immunfärbung wurden bei 13 von 28 Patienten beobachtet (Stadium B; 46%), davon neun SLN und vier non-SLN. Ein SLN-Nachweis war erfolgreich, obwohl die Lymphknoten nicht sichtbar waren. Gezielte Untersuchung der SLN wies sieben Fälle (17.5%) eines zusätzlichen Upstagings für das Tumorstadium pT1–3 N0 M0 nach.Schlussfolgerung:Upstaging durch die Kombination von Immunfärbung und SLN-Mapping kann großen Einfluss auf eine adjuvante Behandlung in zukünftigen Behandlungsprotokollen haben.

Evaluation of anatomical and functional results of overlapping anal sphincter repair with or without the injection of bone marrow aspirate concentrate: a case-control study

Overlapping anal sphincter repair (OASR) is used for treatment of faecal incontinence due to an external anal sphincter (EAS) defect; however, it is not the optimal treatment as its functional results tend to deteriorate significantly with time. The present study aimed to evaluate the effect of local injection of bone marrow aspirate concentrate (BMAC) on the outcome of OASR.

Excision with primary midline closure compared with Limberg flap in the treatment of sacrococcygeal pilonidal disease: a randomised clinical trial

BACKGROUND Although several surgical techniques for treatment of sacrococcygeal pilonidal sinus (SPND) have been described, there is no consensus on the optimal surgical procedure. In this study we compared excision with primary closure and Limberg flap in the treatment of SPND. METHODS This was a prospective randomised clinical trial in patients with SPND who were randomly allocated to one of two groups: group I (excision and primary closure) and group II (Limberg flap technique). The primary outcome of the trial was recurrence of SPND whereas postoperative complications, return to work and cosmetic results were the secondary outcomes. RESULTS Sixty patients were included, with a mean age of 24.1 years and mean body mass index (BMI) of 26.8 kg/m2. Group 1 had significantly shorter operation time than group II. Both groups had similar hospital stay and comparable complication rates (43.3% vs 30%; P = 0.4). Group I had significantly higher recurrence rate (20% vs 0; P < 0.02) and significantly better cosmetic satisfaction score than group II. Being hairy (P = 0.04), positive family history (P = 0.03), diabetes mellitus (P = 0.005) and history of previous surgery for SPND (P = 0.01) were the significant predictors for recurrence. CONCLUSIONS The Limberg flap is an effective technique for the treatment of SPND with very low recurrence rate and comparable complication rate and hospital stay to excision and primary closure. Excision and primary closure offered the advantages of quicker healing time, earlier resumption of daily activities, better cosmetic results, which may render it more suitable for patients with low risk for recurrence.

Pattern of major injuries after motorcycle accidents in Egypt: The Mansoura Emergency Hospital experience:

Background and aim Motorcycle accidents are one of the leading causes of road traffic injuries and mortality. The aim of this study was to determine the common patterns of major injuries associated with motorcycle accidents in patients attending Mansoura University Emergency Hospital in Egypt, and to measure the magnitude of the problem in our community. Patients and methods Patients involved in motorcycle crashes who were admitted to the hospital during August 2014 to April 2015 were retrospectively reviewed. All age groups and both genders were included. Results Two hundred patients (181 males) with a mean age of 30.7 ± 10.5 years were included with the majority of patients aged 20–40 years. Head injuries were the most frequent fatal injuries (9/61) patients; orthopedic injuries were the most common injuries, occurring in 78.5% of victims. Multisystem injuries occurred in 28% of patients. None of the motorcyclists involved in accidents wore helmets. Conclusion Motorcycle accidents are a common cause of road traffic injuries and mortalities in Egypt, occurring mainly in males aged 20–40 years. The majority of victims had an isolated trauma to single body system. Orthopedic injuries were the most common and least fatal type of injuries. The highest fatalities were among patients with chest injuries then patients with head injuries. None of the victims wore protective clothing or helmets at the time of accident.