Waleed Elnahas

Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection

BackgroundReconstruction of large scalp defects after tumor resection is a challenging problem. We aimed at putting an algorithm for reconstruction of those defects.MethodsForty-two patients with scalp malignancies were enrolled in this study. Tumors were resected to a 1 cm negative margin and defects were reconstructed according to their size and to patient general condition.ResultsNo peri-operative mortality was encountered. Usage of free flaps was superior in cosmoses and function with an acceptable rate of complications.Conclusionfor scalp defects wider than100 cm2, the best tool of reconstruction is free flaps. Pedicled distant flaps are reserved if free flaps are not feasible or failed. Split thickness skin grafts are cosmetically inferior and not suitable for recurrent and irradiated tumours and better reserved for patients who cannot tolerate major operations.

Pharyngoesophageal reconstruction after resection of hypopharyngeal carcinoma: a new algorithm after analysis of 142 cases

BackgroundThe aim of this study is to define an algorithm for the choice of reconstructive method for defects after laryngo-pharyngo-esophagectomy for hypopharyngeal carcinoma.MethodsOne hundred and forty two cases of hypopharyngeal carcinoma were included and operated on by either partial pharyngectomy, total pharyngectomy or esophagectomy. The reconstructive method was tailored according to the resected segment.ResultsPectoralis flap was used in 48 cases, free jejunal flap in 28 cases, augmented colon bypass in 4 cases, gastric pull up in 32 cases and gastric tube in 30 cases. Mean hospital stay was 12 days. Mortality rate was 10.6% and morbidity rate was 31.7%. Total flap failure occurred in 3 cases of free flap and one case of pectoralis flap. There were 23 cases of early fistula. Late stricture occurred in 19 cases, being highest with myocutaneous flap (early fistula 12/50 and late stricture 13/50).ConclusionFree jejunal flap was the flap of choice for reconstruction when the safety margin is still above the clavicle. In cases with added esophagectomy, we recommend gastric tube as a method of choice for reconstruction.

Therapeutic reduction mammoplasty in large- breasted women with cancer using superior and superomedial pedicles

BACKGROUND Surgical management of breast cancer in large-breasted women presents a real challenge. This study aims to evaluate the outcome of therapeutic reduction mammoplasty in large-breasted women with breast cancer using superior and superomedial pedicles, situated at any breast quadrant except for the central and upper medial quadrants. METHODS Fifty women with breast cancer and large breasts underwent simultaneous bilateral reduction mammoplasty. The weight of the tissue removed ranged from 550 g to 1050 g and the tumor-free safety margins by frozen section were in the range of 4 cm to 12 cm. RESULTS The age of the patients ranged from 36 to 58 (median 43) years and tumor size ranged from 1 cm to 4 cm. The cosmetic outcomes were excellent in 32 patients (64%), good in 15 (30%) patients, and fair in three patients (6%). The follow-up period was 8-36 (mean 20) months, with no local recurrence or systemic metastasis. CONCLUSION Therapeutic reduction mammoplasty using superior and superomedial pedicles was shown to be oncologically safer than traditional conservative surgery. This oncoplastic procedure yields a satisfactory esthetic outcome with lower morbidity in large-breasted women with breast cancer.

Unifocal Differentiated Thyroid Cancer Smaller than 1 cm are Better Managed by Total Thyroidectomy

Background: The optimal extent of surgery for differentiated thyroid cancers (DTC) is controversial. The aim of this study is to assess the frequency and potential predictive factors of residual malignancy in the lobe contralateral to the main tumor. The secondary aim was to assess the safety of completion thyroidectomy. Methods: All total thyroidectomies performed at our institution between 2004 and 2010 were reviewed identifying 185 patients (70 cases underwent completion thyroidectomy and 115 cases underwent initial total thyroidectomy). The predictive value of sex, age, tumor size, histology, multifocality, perithyroid extension, and lymph node involvement was analyzed. Results: we report a high rate of multifocality (51%) in the whole cohort of cases and of contralateral disease (35%). There were no differences in multifocality rates for sex, age, pathology types and tumor size. PTC cases 1 cm (45% versus 59% respectively). Moreover, there was no significant correlation between ipsilateral multifocality and contralateral disease in our cases. In our series, the complication rates for both completion thyroidectomy and total thyroidectomy were comparable. Conclusion: Absence of significant predictive factors that could suggest a residual disease justifies total thyroidectomy as a primary treatment for cases of DTC. Hemithyroidectomy for management of cases of DTC smaller than 1 cm with absence of multifocal disease in the ipsilateral lobe should be questioned.

Axillary lymph nodes metastasis in a patient with recurrent papillary thyroid cancer: a case report

IntroductionThyroid cancer is the most common endocrine malignancy; the most common type of thyroid cancer is papillary thyroid cancer which accounts for approximately 90% of all thyroid cancers. Previously defined prognostic factors of papillary thyroid cancer include age, gender, tumor size, extrathyroidal extension, and distant metastasis. Cervical lymph node metastases are very common in patients with papillary thyroid cancer. Although papillary thyroid cancer has an excellent prognosis, lymphatic spread is associated with an increased risk of locoregional recurrence.Axillary metastasis is not a common finding in the classic type of papillary carcinoma; hence, a limited number of case reports have described the exceptional and rare metastatic spread of papillary thyroid carcinomas to the axilla.Case presentationWe report a case of metastatic axillary lymphadenopathy in a 61-year-old Egyptian man with a recurrent papillary thyroid cancer. He had a history of total thyroidectomy with right radical neck dissection 18 months ago. He presented to our cancer clinic at the Oncology Centre –Mansoura University with recurrent mass at the right lower parotid region, left cervical lymphadenopathy and left axillary lymphadenopathy.Removal of the recurrent right intraparotid mass, left comprehensive neck dissection and left axillary dissection were performed and the postoperative pathology report showed infiltration of the cervical and axillary lymph nodes by metastatic papillary thyroid cancer.ConclusionsAxillary lymph node enlargement in a patient with papillary thyroid cancer should be considered metastatic from thyroid until proved otherwise. Careful thorough examination of patients with recurrent thyroid cancer is essential to address any unusual metastasis.

Accuracy of Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients; Single Center Experience

Purpose: Most important factor affecting prognosis of breast cancer is axillary nodal involvement. Several studies evaluated the accuracy of Sentinel lymph node biopsy in breast cancer patients post neoadjuvant chemotherapy. In this study, we will examine accuracy and feasibility of using Sentinel lymph node biopsy in predicting axillary lymph node status in breast cancer patients after neoadjuvant chemotherapy. Methods: 45 female patients with resectable, nonmetastatic breast carcinoma cases who received neoadjuvant chemotherapy were enrolled in this study according to the routine Mansoura Oncology Center—guidelines of management of breast cancer. Methylene blue dye used for detection of Sentinel lymph node. Results: Successful Sentinel lymph node detection was 82.2%. Skin involvement (T4 disease) were linked to a low identification (P = 0.005). False negative rate equals 11/27 = (40.7%).With advancement of the stage of the tumor, the incidence of false negative results increases significantly (p = 0.012) with 95% confidence interval; 1.2 - 5.4. Conclusion: Sentinel lymph node should be adopted to be the standard method for axillary staging with T1-3 tumors after receiving neoadjuvant chemotherapy, in T4 patients, it is associated with low detection rate & high false negative rate making it doubtful technique for axillary staging.

Transanal Total Mesorectal Excision for Rectal Cancer: Short Term Outcomes from Two Centers

BACKGROUND Rectal cancer is now an increasing problem in both developed and developing countries. In the last 7 years, minimally invasive surgery for this disease has entered a new era of transanal resection with/without laparoscopic assistance. MATERIALS AND METHODS We present here a prospective study done in Egypt (probably the earliest experience) and Spain on the feasibility of hybrid NOTES in rectal cancer. RESULTS From September 2015 till November 2017, 18 cases underwent transanal total mesorectal excision with no detected mortality and with morbidities in 44% of cases, from which 5 were class III on Clavien-Dindo scale requiring intervention. Good quality total mesorectal excision was obtained in more than three quarters of our patients. CONCLUSIONS In our experience, the technique was technically demanding with a long learning curve; however, the short term results were very good in alliance with other few similar reports.

Lateral Versus Anterior Approach Laparoscopic Splenectomy: A Randomized-controlled Study

Purpose of the Study: The study compares prospectively the hospital stay and postoperative complications of anterior (ALS) versus lateral (LLS) approach for laparoscopic splenectomy. Materials and Methods: Between September 2011 and April 2015, 94 patients with splenomegaly were referred to the surgical unit in the Oncology Center of Mansoura University, Egypt. Only 80 patients with splenomegaly <30 cm underwent an open-label randomized allocation into 2 equal parallel groups. Indications were hematological in 52 patients (65%) and malignant splenic conditions in 28 patients (35%). Two patients younger than 18 years, 4 patients with splenomegaly >30 cm, and 8 patients with associated surgical comorbidities were excluded. Three days’ hospital stay reduction with LLS was suggested with a power of 80% and P-value of 0.05. Results: The mean hospital stay was significantly shorter (P=0.001) after LLS. Laparoscopic splenectomy was completed in 68 patients (85%). Twelve patients (15%) required open splenectomy with no difference between groups. The operation time was significantly shorter in LLS (P=0.013). Blood loss (P=0.057) and blood transfusion (P=0.376) showed no difference between the two groups. The times until resumption of oral intake (P=0.019) and drain removal (P=0.011) were statistically shorter in LLS. Conclusions: LLS is more safe and feasible with shorter hospital stay compared with ALS.

Continent Catheterizable Umbilical Low-Pressure Intestinal Pouch with Split Ileal End Seromuscular Anti-Reflux Technique

BACKGROUND Cosmesis, better function, and stomal stricture avoidance are important issues in constructing continent urinary abdominal stomas for bladder cancer patients when orthotopic urinary diversion is not feasible. This study aims to evaluate the outcome of continent catheterizable umbilical low-pressure intestinal pouch incorporating a new split ileal end anti-reflux technique. METHODS Twenty-three patients underwent a continent umbilical low-pressure intestinal pouch incorporating a new seromuscular antireflux technique (split ileal end) after radical cystectomy when orthotopic reconstruction was not feasible. Mean operative time was 210 min (130 min for radical cystectomy and 80 min for reconstruction of the pouch). The mean follow-up after surgery was 18 mo (range 6-30 mo). RESULTS The most common early postoperative complications were urinary leak that occurred in nine patients: seven were conservatively managed and two by re-exploration. Late postoperative complications occurred in eight patients, of whom three developed stomal stenosis and treated successfully with repeated dilatation. Thirteen patients were totally continent, seven were fairly continent, and only two were poorly continent. CONCLUSIONS The functional results with this catheterizable umbilical low pressure intestinal pouch incorporating our new anti-reflux technique were satisfactory with better cosmesis.