El-Demerdash Hospital Research Articles

Study of Management of Post Bariatric Surgery Complications in El Demerdash Hospital from January 2022 to June 2023

Abstract Background Obesity is an increasing health concern in the United States and worldwide. According to the World Health Organization, obesity has doubled since 1980. In 2014 alone, more than 1.9 billion adults were classified as overweight, of which 600 million were obese. Durable medical therapy for morbid obesity is limited. As an alternative, many studies have demonstrated the benefits of bariatric surgery in terms of excess weight loss and improvement or resolution of weight-related co- morbid diseases. As of 2013, the most commonly performed laparoscopic bariatric procedures worldwide are Roux-en-Y gastric bypass (RYGB) (45%), sleeve gastrectomy (SG) (37%) and adjustable gastric banding (AGB) (10%). Objective To report and analyze the management of complications after bariatric surgery in the bariatric surgery unit in El Demerdash hospital from January 2022 to June 2023. Methods This was a retrospective and prospective Study that was conducted at General surgery department, Ain Shams University Hospitals from January 2022 to June 2023 on 25 patients who underwent bariatric surgery and developed postoperative complication. In our study, the ages of the studied cases ranged from 15 to 65 years (mean 34 years). Results The results of our present study can be summarized as follows: •The ages of the studied cases ranged from 15 to 65 years (mean 34 years). •There were 6 (24.0%) Male cases and 19 (76.0%) Female cases. •56.0% of cases had Co morbidities, Including nine cases of DM (64.3%), five cases of HTN (35.7%) and three cases of Asthmatic (21.4%). •The Most common bariatric surgery that was performed for more than half of the cases was LSG, Followed By LRYGB, while the Time of presentation by a complication ranged from 0.07 to 240 months (mean 12 months). •The Complications that all cases were exposed to, as there were five cases that were exposed to Gallbladder stones (20%), five cases that were exposed to weight regain (20%) and three cases that were exposed to Leakage (12%). The less common complications are internal hernia (8%), MVO (8%), and repeated vomiting (8%). Other complications include chronic constipation (4%), dysphagia and heart burn (4%), infected hematoma (4%), leakage due to perforated anastomotic ulcer (4%), malnutrition (4%), and port site hernia (4%). •The most common management is laparoscopic cholecystectomy (20%), followed by laparoscopic mini gastric bypass (LMGB) (20%). Other managements include redo open GB (8%), resection anastomosis of gang bowel (4%), endoscopic dilatation (4%), exploration and total enterectomy (4%), herniaplasty with mesh 15 x15 (4%), LGB (4%), pigtail (4%), pigtail at collections and mega stent (4%), reduce the herniated bowels and closure of the defect by vicryl (4%), reduction of gastric sleeve, standard posterior hiatal hernia repair, resection of SG and conversion to LGB (4%), reduction of intesuseption without revision of anastomosis (4%), supplementations (4%), T tube in the perforated anastomotic ulcer (4%), and no intervention (4%). •According to outcome, (88.0%) Cured and (12%) died Conclusion The study highlights that among bariatric surgeries, Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux en Y Gastric Bypass (LRYGB) were the most frequently performed, with LSG being the most common. The study identified gallbladder stones, weight regain, and leakage as the most prevalent complications, predominantly managed through laparoscopic cholecystectomy and laparoscopic mini gastric bypass. Overall, the bariatric surgery cohort exhibited an 88% cure rate but with a 12% mortality rate. Remarkably, patients with comorbidities had a higher cure rate than those without, with diabetes showing the highest cure rate among comorbidities. Notably, gallbladder stones were associated with a lower death rate, whereas mesenteric vessel occlusion (MVO) and malnutrition were linked to higher mortality rates. Our study's findings suggest that bariatric surgery is a safe and effective procedure for weight loss. However, it is important to be aware of the potential complications, and to seek prompt medical attention if any complications occur.

Effectiveness of U/S Guided Erector Spinea Plane Block for Post-Operative Pain Control in Breast Surgeries

Abstract Background Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related mortality among females in more than 100 countries. The traditional therapeutic approaches for breast cancer include surgery, radiation therapy, chemotherapy, Immunotherapy and endocrine therapy, surgical resection is still considered to be the primary and most effective therapy. Objective To evaluate the analgesic effect of ultrasound-guided erector spinae plane (ESP) block in breast surgery postoperatively Methods This was randomized controlled clinical trial that was held in major operating theaters in el demerdash hospital, Ain Shams University, Cairo, Egypt for 6 months on females undergoing breast surgeries aged between 21 - 45 years. Results Our results reported that there was highly statistically significant difference found between Group I and Group II regarding Postoperative pain scores Immediately, Postoperative pain scores After 5min, Postoperative pain scores After 10 min, and there was no highly statistically significant difference found between Group I and Group II regarding Postoperative pain scores After 15min, Postoperative pain scores After 20min, Postoperative pain scores After 25min and Postoperative pain scores After 30min. There was highly statistically significant difference found between Group I and Group II regarding Total morphine consumption (mg) and Number of patients requiring morphine. Also, there was highly statistically significant difference found between Group I and Group II regarding Mean arterial blood pressure (mmHg) Immediately, and there was no highly statistically significant difference found between Group I and Group II regarding Mean arterial blood pressure (mmHg) After 5min, Mean arterial blood pressure (mmHg) After 10 min, Mean arterial blood pressure (mmHg) After 15 min, Mean arterial blood pressure (mmHg) After 20 min, Mean arterial blood pressure (mmHg) After 25 min and Mean arterial blood pressure (mmHg) After 30 min. Regarding Patients satisfaction, there was statistically significant difference found between Group I and Group II Conclusion Ultrasound-guided ESP block with general an aesthesia offers superior post-operativeanalgesia compared to general an aesthesia alone in patients undergoing unilateral non-reconstructive breast cancer surgeries and is associated with better patient satisfaction scores at discharge. There was no significant difference in intraoperative morphine consumption. The ultrasound-guided ESP block appears to be an effective block for postoperative analgesia in breast cancer surgery.

Clinical Efficacy of Medial and Lateral Plating in Distal Femur Fractures: Thesis Study

Abstract Background The problem of treating distal femoral fractures is complicated. The principles of the surgical management of supracondylar femur fractures have changed. Up until 1970, conservative management of these fractures was the recommended course of care. This was mostly caused by a lack of adequate implants and procedures. In modern times, locking compression plates offer the benefits of locking head screws, offering better fixation and absolute stability. This is significant in the treatment of fractures in osteoporotic bone because it enables the use of monocortical screws in the diaphyseal region, preserving the periosteum's blood supply and preventing structural bone loss to the opposite cortex. Varus collapse was the main complication, especially in osteoporotic bone. Therefore, anatomical reduction and rigid, stable fixation provided by double plating was considered the best option for treating this type of fracture. Patients and Methods This is a retrospective cohort study done in El Demerdash Hospital, Ain Shams University specialised hospitals, Air Force specialised hospital, and El Helmia military hospital through 20 cases of distal femur fractures of types 33-A3 to 33-C3, all of which were managed by dual plating and followed up for 6 months. People with open fractures, fracture type 33-A1, periprosthetic, and pathological fractures were excluded. Results In our study, through 20 cases with distal femur fractures between types 33-A3 and 33-C3, all managed by double plating, the mean age was 51.50, 6 of our patients had comorbidities (DM, HTN, or Both), the rest were medically free, the average operation time was 150 minutes, 2 of our patients needed a bone graft, the range of full union was from 3 to 6 months, the average AKSS among the 20 patients was 81.05, 14 of our cases achieved uneventful union, 2 cases had superficial wound infection, and 1 case had implant failure (screw cut out) and needed revision, so double plating is one of the better options to achieve bony union and a better functional outcome in severely comminuted distal femur fractures Conclusion Even though there were problems such as a lengthy operation and longer recovery period in our study, double plating is one of the best options for achieving bone union and a better functional outcome in severely comminuted distal femur fractures. Functional outcomes were excellent in 75% of cases and fair in 25% of cases, and the union rate was 100% with no Varus deformity or malunion.

Diagnostic Yield of the Number of Duodenal Biopsies in Celiac Disease

Abstract Background The diagnosis of celiac disease relies on a combination of clinical evaluation, serological testing, and histopathological examination of duodenal biopsies. However, there is ongoing debate regarding the optimal number of duodenal biopsies required for an accurate diagnosis, as well as the isolated yield of water interface directed biopsy. Aim The primary objective is to determine the cumulative benefit of multiple duodenal biopsies, establishing the specificity and sensitivity of each biopsy separately with focus on the isolated yield of water interface directed biopsy. Methods A Cross-sectional study conducted on 22 children with symptoms and signs suggestive of celiac disease (CD) and positive serology with antitissue transglutaminase antibodies at the pediatric gastrointestinal endoscopy Unit at EL Demerdash Hospital, Ain Shams University for 6 months. four biopsies were taken, one from duodenal bulb, and 2 from rest of duodenum and the fourth one using water immersion technique visualizing the most affected area. Results Among the 22 enrolled children, 18 patients were histopathologically positive for celiac disease and 4 children were negative. The bulb, duodenal, and water interface biopsies were positive in 94.4%, 88.8%, and 66.7% respectively, of those positively diagnosed as celiac disease by Marsh criteria. In addition, bulb, and duodenal biopsies have the highest sensitivity of 94.4%, and 88.9%, respectively, also, they have the highest accuracy. Duodenal bulb biopsies were capable alone to diagnose 17 out of 18 definite cases. The missed case diagnosis was reached either by water interface or any random duodenal biopsy. Conclusion Bulb biopsy showed to be the most accurate in diagnosing celiac disease, on the contrary, water interface biopsy was not sensitive in diagnoses, so the celiac diagnostic efficacy can be reached by assessment of 2 duodenal biopsies, one of them from the duodenal bulb.

Evaluation of Shape and Volume Restoration of Orbit after Reduction of Orbitozygomatic Fractures

Abstract Background The appearance of the Orbitozygomatic complex (OZC) fracture terminology is contributed to the fact that a fracture in the lateral side of the midface is not strict to anatomical boundaries, however, it involves the zygoma, maxilla and orbital structures. Orbitozygomatic complex fractures are one of the most commonly encountered injuries of the craniofacial skeleton. The solid zygomatic bone acts as a part of the vertical and horizontal facial buttress, along with the malar eminence, which plays a key role in the determination of facial morphology. It forms a significant portion of the floor and lateral wall of the orbit thus it acts as one of the most common contributors to the orbital integrity, restoration of orbital volume is essential to prevent enophthalmos. Objective Evaluate restoration of orbital shape, volume and globe position in the anterior-posterior plane after reduction of zygomatico-orbital fractures. Methods This Prospective observational study was done from March 2023 to August 2023 at plastic, burn and maxillofacial department in El Demerdash Hospital, Ain Shams University. Eighteen (18) adult patients, complaining of post traumatic orbito-zygomatic fractures requiring operative intervention, were included in this study. Evaluations of orbital shape and differences between orbital volume measurements (damaged orbits compared to intact orbits before and after surgery), orbital volume calculated from area marked by delineating bony landmarks of the orbit interconnected by freehand cursor manually on a series of CT slices in the axial plane, the CT images were exported to the CMF orbital analysis software (adw4.7), where the volume was calculated automatically, Depth: measured from orbital rim to the orbital apex, from outer optic foramen to the middle point of a line passing through lateral and medial orbital rims; width: Maximal horizontal distance from lateral to medial rim and height: measured from superior to inferior margin at their maximum distance perpendicular to orbital width. Results The mean volume of the affected orbit throughout our study showed significant decrease from 24.81 ± 2.04 cm3 before the operation to 23.38 ± 2.22 cm3 after the surgical intervention (P < 0.001), indicating a highly significant difference, where volume has significantly increased on fractured side preoperative in comparison to the sound side (P = 0.016) indicating significant effect of trauma on increasing orbital volume from normal, while no statistical difference was noted (P = 0.75) between orbital volume of fractured side postoperatively 23.38 ± 2.22 cm3 and the sound side 23.24 ± 1.64 cm3, indicating proper reduction and restoration of orbital volume to near normal postoperatively, increased depth (45.46 ± 3.26), width (38 ± 2.94) and height (35.7 ± 2.98) of fractured side preoperatively; this increase was statistically significant, While Depth and width showed more increase than height; values were more statistically significant and return to near normal postoperatively (42.96 ± 2.68), (36 ± 2.88) and (34.23 ± 3.45) respectively; this decrease was still significant statistically except for height where it was non-significant, indicating better restoration of height than depth and width attributed to its lesser increase from the first place, as values of sound side weree (41.64 ± 2.25), (34.56 ± 3.25) and (34.51± 3.52) respectively. Conclusion Our study suggests that the surgical reduction of orbitozygomatic fractures has a significant role in restoration of the orbital shape, volume, and globe positioning in the anterior-posterior plane. And that enophthalmos occurrence is greatly influenced by increase of the bony orbital volume, also it’s affected by other factors for further research. Orbital dimensions were affected by trauma and restored to near normal after reduction but showed no major shape changes of the conical orbit.

Role of Serum Alpha-1-Acid Glycoprotein as a New Biomarker for Cirrhotic and Hepatocellular Carcinoma Patients

Abstract Background Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide, it is the second leading cause of malignancy related mortality all over the world and is primarily due to the hepatitis C virus (HCV) epidemic. Aim of the Work to evaluate the diagnostic value of serum AAG level as a novel biomarker for HCC and cirrhotic patients Patients and Methods This study was conducted on ninety cases chosen from El Demerdash hospital (Ain Shams University) divided into three groups group (A) ten normal control people, group (B) forty known HCC patients which was further subdivided into two small subgroups B (I) twenty with low AFP level and B (II) twenty with high AFP level, as well as forty patients with liver cirrhosis group (C) during the period from June 2022 to December 2022. Results The mean value of AAG in HCC low AFP cases was 1307 μg/ml which was higher than that of patients with HCC high AFP (850 μg/ml) and chronic liver disease patients (309 μg/ml). AAG as a diagnostic marker for HCC the cut-off value was 740 ng/ml with sensitivity 73% and specificity 74% for HCC low AFP, which was higher than that of patients with HCC high AFP sensitivity 68% and specificity 71%. Conclusion Alpha 1 Acid Glycoprotein had better performance in diagnosing HCC patients with low AFP. Serum Alpha 1 Acid Glycoprotein (AAG) concentrations can used as a potential marker for hepatocellular carcinoma.

The Validity and Reliability of CT Scan Based Tibial Plateau Mapping for Tibial Plateau Fractures

Abstract Background Tibial plateau fractures are intra-articular fractures presume a threat to knee function and represent great challenge to treat. Treatment with open reduction and internal fixation is variable because fractures vary from simple to complex, with little or extensive articular involvement. Hence, recognition of the fracture features will help orthopedic surgeons to understand the injury mechanism better and manage these fractures by planning optimal surgical procedures. Aim of the Work To assess the inter and intra-observer reliability of the new CT scan based tibial plateau classification (the ten segment tibial plateau mapping) and the secondary aim is to clarify its validity in clinical practice assisting the surgeons in choosing their approach and fixation implant during open reduction and internal fixation of such fractures. Our hypothesis is that this more sophisticated classification system may facilitate the choice of surgical approach and implants used and that this classification could be widely accepted among trauma surgeons. Patients and Methods A total of 30 patients with tibial plateau fractures diagnosed by the department of orthopedic surgery at el Demerdash hospital, Ain Shams university were collected in the time period between January 2020 and December 2022. Results in our study, we compared the inter and intra observer reliability of Schatzker, three column, and ten-segment classification using Kappa values. The results showed that schatzker and three column classification systems have higher inter-observer mean kappa values (0.749± 0.07, 0.692± 0.08) (0.639± 0.06, 0.667± 0.08 after 2 weeks‟ time interval) respectively representing good interobserver agreement in relation to the ten-segment classification which showed mean Kappa value 0.409± 0.30 representing moderate interobserver agreement when the cases were observed for the first time. The mean Kappa value decreased (0.081± 0.17) when the cases were observed after 2 weeks‟ time interval representing poor interobserver agreement. As regard to intra-observer reliability, both schatzker and three column classifications have higher mean Kappa values (0.766± 0.22, 0.697± 0.17 respectively) representing good intra-observer agreement in relation to ten segment classification which showed mean Kappa value (0.342± 0.10) representing poor intra-observer agreement. Conclusion tibial plateau fractures represent great challenge for orthopedic surgeons to treat and adequate preoperative planning is mandatory. The use CT scan with 3D reconstruction can help surgeons to describe and classify all fracture patterns thus reaching the optimal plane for fracture fixation. Our study concluded that ten segment classification has moderate to poor reliability compared to the conventional widely used schatzker classification and three column classification. We think that this because ten segment classification still not familiar to orthopedic surgeon. More research is needed on ten segment classification so that it can be applied in the future in clinical practice.

Tumescent Technique for Transabdominal Preperitoneal Inguinal Hernia Repair (TAPP) versus Conventional TAPP

Abstract Background Laparoscopic hernia repair is more difficult technically than open surgery and there is evidence of learning curve in its performance and many complications reported from laparoscopic procedure. But also, laparoscopic approach has its benefits as rapid recovery, quicker return to work, less acute pain complication, better quality of life outcomes. Objective To compare between the conventional and tumescent technique in TAPP inguinal hernia repair as regards operative technique, intra & post-operative complications, early post-operative pain, hospital stay, restriction of physical activity, incidence of recurrence and post-operative chronic groin pain. Methods This was a prospective, randomized, comparative study, that was conducted at El-Demerdash hospital over one and a half years (October/2021 - March/2023). The 60 patients who were included divided into two groups, 30 for each. Group A; tumescent technique, Group B; conventional technique. Results Follow up started from the first day after operation and then visits at surgery outpatient clinic were arranged as follows, two weeks postoperative, then after one month. Interpretation of results revealed that there was significant difference between the two groups in operative time and early post-operative pain which decreased in tumescent group. There was no significant difference between the two groups as regards postoperative complications, the most reported complications were post- operative urinary retention and seroma formation. No reported cases of hernia recurrence and chronic groin pain in both groups. Conclusion Tumescent TAPP inguinal hernia repair appears to offer technical and clinical improvements to conventional TAPP, with small learning curve makes it easy procedure for unexperienced surgeons to use it for hernia repair and to learn it quickly. In general, TAPP inguinal hernia repair is considered both safe and effective for surgeons skilled in laparoscopic surgery; as all perioperative complications are well tolerated by patients and mostly there was no need for a second operative intervention, also the short-term treatment results were satisfactory.

Ultrasound Guided Transversus Abdominis Nerve Block versus Bilateral Ultrasound Guided Ilioinguinal-Iliohhypogastric Nerve Block in Elective Cesarean Section in El-Demerdash Hospital. A Randomized Controlled Trial

Abstract Background Pain after CS is a primary concern of women and the provision of effective analgesics is an essential duty for the obstetric anaesthetist. After the application of ultrasound in anesthetic practice, we can now choose between a landmark- or ultrasound-guided TAP block, Ilio- inguinal nerve block (alone or in combination with an Iliohypogastric nerve block) among others. Objective To compare the effect of bilateral ultrasound guided TAP block versus ultrasound guided Ilioinguinal and Iliohypogastric nerve block on post-operative analgesia in patients undergoing elective Cesarean section under spinal anesthesia. Patients and Methods The study was conducted on 64 random patients per each group who were scheduled to undergo elective cesarean section under spinal anesthesia, the two groups were as following; Results As for the comparison between effect of TAP block and ilioinguinal-iliohypogastric block as regard post-operative pain in elective cesarean section under spinal anesthesia, it showed that there is significance regarding the numeric version of the VAS score and its intensity. These findings the TAP block more effective than the ilioinguinal-iliohypogastric block. These findings with our primary and secondary outcomes showed that TAP block has more analgesic effect with respect to ilioinguinal-iliohypogastric block regarding pain assessment but with no significant difference regarding the time till first analgesia postoperative and total analgesics consumption over 24-hour period post-operative. Conclusion The comparison between effect of TAP block and ilioinguinal-iliohypogastric block as regard post-operative pain in elective cesarean section under spinal anesthesia showed significant difference regarding the numeric version of the visual analogue scale (VAS) that was used to assess postoperative pain and its intensity. These findings with our study primary and secondary outcomes showed that TAP block has more analgesic effect with respect to ilioinguinal-iliohypogastric block regarding pain assessment and the time till first analgesia postoperative and total analgesics consumption over 24-hour period post-operative.

Opioid Free Ptyregopalatine Ganglion Block Based Multimodal Anesthesia Versus Conventional Opioid Based Multimodal Anesthesia for Tonsillectomy Operations: A Randomized Controlled Trial.

Otolaryngology often involves adenotonsillectomies, surgical procedures aimed at addressing obstructive sleep-disordered breathing and underlying apnea in children. Pediatric anesthesiologists and otolaryngologists encounter challenges in managing pain post-adenotonsillectomy, especially due to the use of opioid medications in children who have an elevated baseline risk of airway obstruction and associated morbidity and mortality. This prospective, randomized, double-blinded study was conducted at Eldemerdash Hospital, Ain Shams University, Egypt, from September 2022 to August 2023. A total of 90 patients aged 5 - 13 years who underwent elective tonsillectomy surgery were randomly assigned to two groups, with 45 patients in each group. The first group, referred to as group A, received intravenous 1.0 μg/kg fentanyl, dexamethasone 150 μg/kg, and paracetamol 15 mg/kg. The second group, referred to as group B, received dexamethasone 150 μg/kg and paracetamol 15 mg/kg, with an opioid-free pterygopalatine ganglion block for multimodal anesthesia. The primary outcome measure of this study was the postoperative Wong-Baker scale at 1st, 3rd, and 24th hours. This study included 90 individuals with similar demographic profiles and comparable initial characteristics and surgical techniques in both groups (P > 0.05). Intraoperative heart rate, mean blood pressure, additional analgesia, postoperative Wong-Baker scale, postoperative rescue analgesia, and laryngospasm did not show significant differences between the two groups (P > 0.05). However, there were statistically significant differences between the groups in terms of nausea, vomiting, hypoxia, and post-anesthesia care unit stay, with group B experiencing fewer of these issues (P < 0.05). Both conventional opioid-based multimodal anesthesia and opioid-free pterygopalatine ganglion block-based multimodal anesthesia are effective methods for providing analgesia during and after tonsillectomy surgery. The pterygopalatine ganglion block, the latter option, has been found to result in fewer postoperative complications such as nausea, vomiting, and hypoxia. Additionally, patients who receive this type of anesthesia typically require less time in the post-anesthesia care unit.

Fibro-Scan Based Score and Novel Noninvasive Serum Marker, FGF-21, to Assess Liver Fibrosis in Morbidly Obese Patients

Abstract Background (NAFLD) is currently the most common cause of liver disease in the Western world, affecting up to 20- 30% of the general adult population. It is a growing public health problem, because of the increasing prevalence of the pathologies that contribute to its development such as obesity and inflammation status. Aim of the Work The study is aimed to develop and validate noninvasive scoring system for assessment liver fibrosis in morbidly obese patients with NAFLD. Subjects and Methods This is a Prospective cohort study, was carried out on 50 morbidly obese patients selected from internal medicine department, El Demerdash Hospital, through a period of six months. Results There were 32(64.0%) male and 18(35.0%) female with mean age 40.48 (± 12.16) SD. There were 14(27.0%) between (20 -30), 11(22.0%) between (30-40), 9(18.0%) between (40-50) and 16(32.0%) ≥50. Mean Weight (Kg) was 106.6 (± 13.31) SD with range (82.50 – 145.5), mean Height (Cm) was 171.7 (± 6.25) SD with range (158.0 – 185.0), mean BMI (Kg/m2) was 36.17 (± 4.15) SD with range (29.30–43.40), mean Waistcircumference 113.1 (±7.64) SD with range (92.0 – 129.0). There were 37(74.0%) with Co-morbidity. 10(20.0%) have DM, 11(22.0%) have HTN, 11(22.0%) have CDK and 5(10.0%) have COPD. Conclusion That the combination of Fibroscan and, APRI, FGF-21 and FIB-4 methods provides a valuable approach for assessing liver fibrosis in NAFLD patients. This can eliminate the need for liver biopsy in patients without clear indication. In addition, several recent studies have also validated the used of non-invasive markers in the diagnosis of NAFLD. The establishment of a national program for the recognition of NAFLD is therefore essential to reduce the risk of liver disease progression.

Effect of Central Dialysis Fluid Delivery System (CDDS) using high flux dialyzer versus Regular Water Treatment Stations on Endotoxemia and Inflammatory Markers among Prevalent Patients on Regular Hemodialysis

Abstract Background and Objectives Translocated endotoxins derived either from intestinal bacteria or backfiltration, have a wide range of adverse effects on patients. Most end stage renal disease (ESRD) patients have systemic inflammation which increases the risk of morbidity and mortality. The central dialysis fluid delivery system (CDDS) has been used exclusively in Japan since 1960s, and now is being used in Ain Shams University. Our aim of the study is to evaluate the effect of (CDDS) versus single patient dialysis fluid delivery system (SPDDS) on endotoxemia and inflammatory markers among prevalent patients on regular hemodialysis (HD). Methods Eighty Patients were randomly selected from HD units, then divided into two groups, (group I) doing HD using CDDS water purification system at El Demerdash Hospital, (group II) using regular water purification system at Ain Shams University Specialized Hospital. Pre- dialysis and post-dialysis serum samples were obtained to measure endotoxin levels of both groups, as well as postdialysis serum samples were obtained to measure interleukin 6 (IL6) level and highly sensitive Creactive protein (Hs CRP). Results Circulating endotoxemia was most notable in group II, The mean predialysis endotoxin level in group I was 0.07 ± 0.05 Eu/mL, while in group II was 0.20 ± 0.07 Eu/mL and mean of post-dialysis endotoxin level in group I was 0.04 ± 0.02 Eu/mL, while in group II was 0.15 ± 0.03 Eu/mL. IL6 as well as Hs CRP levels were higher in group II in comparison to group I. Conclusion Our data showed significant reduction in circulating endotoxins in CDDS group.

Peripheral Perfusion Index as a Predictor of Post-Spinal Hypotension in Patients Undergoing Lower Abdominopelvic Surgeries

Abstract Background One of the main complications of spinal anesthesia is post spinal hypotension. And since noninvasive hemodynamic &amp; blood pressure monitoring are the standards in most surgical procedures, ensuring best &amp; safest monitoring standards has been of utmost importance. The use of plethysmography in anesthesia monitoring has become one of the essential tools in any anesthetic procedures. However, its varying interpretations &amp; usages haven't been explored to the fullest. Objective To assess predictability of baseline peripheral perfusion index to Post spinal hypotension in patients undergoing elective lower abdomino-pelvic surgeries. Methods This Prospective Observational study was conducted in Ain Shams University Hospitals’ operating rooms. And was conducted over a period of 6 months after approval of ethical committee of Faculty of Medicine, Ain Shams University, All patients undergoing elective lower abdominopelvic surgeries at El-demerdash Hospital of Surgery during the study period. Surgeries include inguinal / inguinoscrotal hernia repair, paraumbilical hernia repair, lower laparotomies, transurethral resection of bladder tumor, simple gynecological procedures. Results This study showed that Perfusion index can be used as a predictor for hypotension in patients undergoing elective lower abdominopelvic surgeries under spinal anesthesia. Patients with baseline PI &amp;gt; 0.9 are at greater risk of developing hypotension after spinal anesthesia when compared with those with baseline PI ≤ 0.9. Hence, peripheral perfusion index usage can be recommended in this regard. Conclusion This study concluded that Perfusion index can be used as a predictor for hypotension in patients undergoing elective lower abdominopelvic surgeries under spinal anesthesia. Patients with baseline PPI &amp;gt;0.9 are at greater risk of developing hypotension after spinal anesthesia when compared with those with baseline PPI ≤0.9 .Hence, peripheral perfusion index usage can be recommended in this regard.

Assessment of the Value of Mean Plathlet Volume, Des Gamma Carboxy Prothrombin and Alpha Feto Protein in Early Detection of HCC

Abstract Background Primary liver cancer is the sixth most commonly diagnosed cancer and the fourth leading cause of cancer mortality worldwide, with an estimated 841,000 cases (9.3 cases per 100,000 person-years) and 782,000 deaths (8.5 deaths per 100,000 person-years) in 2018. HCC being often associated with liver cirrhosis masks symptoms of cancer progression and thus the clinical course of HCC is mostly asymptomatic. Aim of the Work To determine the value of mean platelet volume, Des gamma Carboxy prothrombin and Alfa-feto protein in early detection of Hepatocelluler carcinoma Patients and Methods This case cross sectional comparative study had been carried out after the approval of the Ethics Committees of the faculty of medicine Ain Shams university on 105 subjects, age range 25-68 year selected from: Patients attending Hepatology and virology outpatient clinic at ElDemerdash hospital Also Liver transplantation center at Ain Shams specialized hospital in Cairo after informed consent were taken from the patients Results In this study HCC was found to be more prevalent in men 28 (80.0%) than in women 7 (20.0%). In our study AFP, MPV and DCP were highest in HCC group, followed by CLD group and lowest in control group. The differences between all groups were significant in MPV and DCP, with no significant difference between CLD and HCC in AFP. In the present study, DCP values of HCC group showed a highly significant increase upon comparison with the non malignant groups (II, and III). The sensitivity of DCP was higher than AFP in detecting HCC patients (97.1% versus 54.3%), Conclusion Measurement of MPV is non-invasive, cheap and quick, and may therefore serve as a predictor of HCC in patients with CLD. Low sensitivity and specificity, on the other hand, suggests that this may be an adjunctive parameter to some other markers like AFP. Further studies with larger samples are needed to determine the association of MPV with HCC. For a single test DCP had highest significant diagnostic performance in differentiating HCC from CLD groups. In detection of HCC testing AFP≥ 40.0 if positive considered positive. If negative, retest for DCP≥ 69.3 if positive considered positive, otherwise is negative. This although deceased specificity and Positive predictive value, it raised sensitivity and Negative Predictive Value to 100.0% when combining both AFP and DCP.

Comparative Study of Reflux Esophagitis as a Complication between Mini-Gastric Bypass vs Sleeve Gastrectomy

Abstract Background All currently commonly performed bariatric operations involve manipulation and alteration of gastroesophageal anatomy, resulting in change of multiple physiologic parameters, such as gastric emptying and even the function of the lower esophageal sphincter (LES) itself. Reflux control involves a complex interplay of LES function, esophageal function, and gastric emptying. While all 3 can be affected by any foregut procedure, LES function and gastric emptying are most directly altered in bariatric surgery Aim and Objectives was for discussing the post-operative reflux esophagitis in both Mini gastric bypass &amp; sleeve gastrectomy in the Treatment of Morbid Obesity. Subjects and Methods This prospective comparative study was carried out at ASU Hospital (El-Demerdash Hospital), Al Haram Hospital &amp; other authorized hospitals between July 2017 and March 2019 and ethically approved. The study involved 40 Patients who were targeted to be recruited &amp; randomly ordered to receive either Group 1 (MGBP (n = 20) or Group 2 Results After 6 months of follow up, we found that reflux esophagitis symptoms remained postoperatively among patients who performed SG operation compared to the MGB group (15% vs 5%). This was statistically insignificant (p = 0.737). Although the resolve rate was higher in the SG group compared to the MGB group (15% vs 5%), this was statistically insignificant (p = 0.605). Conclusion LSG and LMGB are both safe and effective procedures for the surgical management of morbid obesity. Bleeding and leakage are the most common and most serious complications in both procedures. The incidence of complications between both procedures is not significantly different.

Evaluation of Retinal Toxicity by SD-OCT due to Long-Term Exposure to Hydroxycholorquine among Rheumatoid Arthritis Patients

Background Hydroxychloroquine is used increasingly in the management of a variety of autoimmune disorders, with well-established roles in dermatology and rheumatology and emerging roles in oncology. However, Hydroxychloroquine and chloroquine (CQ) have been associated with irreversible visual loss due to retinal toxicity. Cessation of the use of hydroxychloroquine at an early stage of damage might prevent functional loss; however, after maculopathy has developed, cessation of the drug does not show clinical recovery. Because discontinuation of Therapy may reverse retinal toxicity, early detection of toxicity changes is vitally important. Objective to evaluate the involvement of retina in hydroxychloroquine (HCQ) retinopathy among rheumatoid arthritis patients using data from spectral domain optical coherence tomography (SDOCT) and to correlate toxicity with dose, duration of use and cumulative effect of HCQ. Patients and Methods Cross sectional Study. In total 13 patients (26 eyes) attending the rheumatological outpatient clinic of El Demerdash hospital, from October 2019 to February 2020 were enrolled in the study after the approval of the research ethical committee in the Faculty of Medicine, Ain Shams University. A full history was taken from the patients and full ophthalmological examination was done. In our study we perform OCT for all patients by using the Nidek RS-3,000 Advance SD-OCT with the “Macula Map” protocol that imaged a 6 × 6 mm area with 64 raster B-scans, each composed of 1024 A-scans. Results The study showed that was highly significant negative correlation between duration of exposure and CMT (p-value =0.008) and highly significant negative correlation between cumulative dose and CMT (p-value =0.005). Also, there was statistically significant negative correlation between age and thickness of inner and outer nasal quadrant (p-value= 0.015, p-value= 0.001) respectively and between age and inner and outer superior quadrant (p-value= 0.048, p-value= 0.000) respectively, in ETDRS thickness map. It also found statistically significant negative correlation between daily dose and thickness of outer nasal quadrant of thickness map (p-value= 0.045). Conclusion The present study show the presence / absence of retinal toxicity in rheumatoid arthritis patients use hydroxychloroquine for 5years or more using SD-OCT and found a statistically significant negative correlation between central macular thickness and cumulative dose of HCQ and between central macular thickness and duration of HCQ use.

Ultrasound Guided Preoperative Assessment of Inferior Vena Cava Collapsibility Index in Prediction of Intraoperative Hypotension in Patients Undergoing Laparoscopic Cholecystectomy Surgery under General Anesthesia

Abstract Background Laparoscopic surgery aims to minimize trauma of the interventional process but still achieve a satisfactory therapeutic results. It is commonly performed because of various advantages such as reduced postoperative pain, faster recovery and more rapid return to normal activities, shorter hospital stay, and reduced postoperative pulmonary complications. Aim of the Work In this study we aim to evaluate effectiveness of preoperative IVC ultrasonography (IVC CI) in prediction of hypotension (mean arterial pressure &amp;gt;60 mmHg) which develops following intraabdomenal gas insufflation, and in determining hypovolemia occurring in patients undergoing laparoscopic cholecystectomy surgery under general anesthesia. Patients and Methods This study was a prospective observational study conducted on 50 patients inside the operative theatre of El demerdash hospital after ethical committee approval. Results There was a statistically significant negative correlation between IVC CI and Change of MBP (mmHg) After induction from baseline with; while Change of MBP (mmHg) After insufflation of abdomen from baseline was of negative correlation but insignificant as there was no dehydrated patients among this study group preoperatively according to our measurements and for ethical purposes we considered that if there was any patient needed hydration preoperative according to preoperative assessment of IVC-CI should be managed before surgery in order not to have intraoperative hypotension which can affect his wellness intra and postoperative, also all the patients were ASA I/II with no critical illness affect volemic status and usage of deprevan, fentanyl and atracurium during induction which can cause hypotension post induction. Conclusion In this study there was a statistically significant negative correlation between IVC CI and Change of MBP (mmHg) After induction from baseline; while Change of MBP (mmHg) After insufflation of abdomen from baseline is of negative correlation but insignificant. We believe that IVC ultrasonography may be helpful in prediction of preoperative hypovolemia in patients who underwent laparoscopic cholecystectomy.

Retrospective Study between Re-sleeve Gastrectomy and Mini-Gastric Bypass for Failed Sleeve Gastrectomy

Abstract Background Overweight and obesity represent a rapidly growing threat to the health of populations in an increasing number of countries. Indeed they are now so common that they are replacing more traditional problems such as undernutrition and infectious diseases as the most significant causes of ill-health. Aim of the Work The aim of this retrospective study is to compare between re-sleeve gastrectomy (RSG) and mini-gastric bypass (MGB) in patients who had previous failed sleeve gastrectomy in the last year concerning time required for operation and hospital stay, complications, and effect on weight loss and comorbidities for each operation. Patients and Methods This study is a retrospective cohart study which included 20 patients 10 of them underwent resleeve gastrectomy and 10 underwent minigastric bypass at Ain-Shams University El-Demerdash Hospital, Cairo, Egypt, From November 2019 to April 2020 with 6 months of postoperative follow up till October 2020. Results In our study we compared between re-sleeve gastrectomy and mini-gastric bypass as a revisional procedure for failed sleeve gastrectomy. MGB had longer mean operative time 103.5 mins. and longer mean postoperative hospital stay 3.6 days versus 91.9 mins. and 2.8 days respectively for RSG. Intraoperatively, bowel injury was reported in 20% of MGB cases versus bleeding which was reported in 20% of RSG cases. Conclusion Mini-gastric bypass and re-sleeve gastrectomy are efficient operations for reducing weight in morbidly obese patients and also in diabetic control. In patients who had previous failed sleeve gastrectomy; mini-gastric bypass had longer operative duration and postoperative hospital stay, more frequent bowel injury and leak in comparison with re-sleeve gastrectomy but improvements of weight loss, BMI, hypertension and DM were better with mini-gastric bypass. The less technically challenging nature of re-sleeve gastrectomy may be more widely applicable.

A Retrospective Study of Management of Gastric Stenosis Post Laparoscopic Sleeve Gastrectomy, Our Institution Experience

Abstract Background Bariatric surgery is the only obesity treatment with long-term efficacy. Of the various surgical techniques available, laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular because of its good weight loss results, its ability to correct comorbidities associated with obesity, and its low post-operative complication rate. The early-onset complications of LSG (i.e., those that appear in the first three post- operative months) include gastric fistula (in 2.5 % of cases, according to a recent meta-analysis) and hemorrhage (in fewer than 5 % of cases). Stenosis is a less frequently described early-onset complication of LSG, with an incidence of 0.69 to 3.5%. Objective To evaluate different strategies of management of post LSG stenosis and the benefit affecting patient's morbidity and mortality and to describe the mechanism of stenosis and its treatment, suggest a standardized approach to management of post-LSG GS on this basis. Patients and Methods This study is a retrospective discreptive study which included patients underwent Laparoscopic sleeve gastrectomy (LSG) at Ain-Shams University El-Demerdash Hospital, Cairo, Egypt and specialized bariatric centers under the supervision of the study modulatrors, Cairo, Egypt From September 2018 to September 2019 with six months of postoperative follow up till January 2020. Results In this study we have revised the data of one thousand patients performed laparoscopic sleeve gastrectomy in our bariatric surgery departement and showed a rate of stenosis of 1%, the mean age was 37.5, mean BMI was 47.9, 5 cases were treated by balloon dilatation, two of the were diagnose as stricture and the other three were diagnosed as twist, another two cases were managed by RYGB, and two cases were managed by MGB, finally one case was conservatively managed along with thiamine deficiency support. Conclusion Gastric stenosis is a rare but potentially life-threatening complication of LSG. Endoscopic treatment (balloon dilatation in particular) is effective, safe, and avoids the need for revisional surgery. If three attempts at dilatation fail, surgery is necessary. Nutritional support and vitamin supplementation are necessary in cases of poor oral feeding with recurrent vomiting.

Pulse Pressure Variation-Based Intraoperative Fluid Management Versus Traditional Fluid Management for Colon Cancer Patients Undergoing Open Mass Resection and Anastomosis: A Randomized Controlled Trial.

Bowel edema leads to decreased perfusion and oxygenation of the intestine at the anastomotic site after colonic mass resection with failure of healing and leakage. Additionally, dehydration causes bowel hypoperfusion and difficulty healing with more complications. Fluid therapy guided by dynamic monitoring of fluid response can help avoid bowel dehydration and edema with fewer complications. The main goal of this study was to compare the effects of intraoperative fluid therapy based on pulse pressure variation (PPV) to traditional fluid therapy to maintain adequate hydration without intraoperative instability of hemodynamics and postoperative complications. This randomized controlled study was conducted on 90 adult patients (age range: 18-70 years) undergoing elective open colonic mass resection and anastomosis at Eldemerdash Hospital, Ain Shams University, Cairo, Egypt. There were two groups of patients, namely group A (n = 45; conventional fluid management [CFM] group) and group B (n = 45; goal-guided fluid management [GGFM] group based on PPV), using randomly generated data from a computer. Intraoperative fluids and vasopressors were given using GGFM or routine care. The key tool for directing hemodynamic management in the GGFM algorithm was the fluid protocol and PPV. As a result, the outcomes were measured to include the volume of intraoperative fluid, water fraction, and postoperative complications. In this study, 90 patients underwent analysis. Both groups' demographics were similar (P > 0.05). Baseline characteristics and surgical procedures did not differ significantly between the two groups (P > 0.05). Both the amount of urine output and the intraoperative administration of crystalloids were statistically significantly higher in group A (P < 0.05). The two groups' heart rate, mean arterial pressure and intraoperative usage of colloids and ephedrine were not statistically different (P > 0.05). Water fraction, bowel recovery, anastomotic leak, and length of hospital stay were significantly higher in the CFM group (P < 0.05). For patients with the American Society of Anesthesiologists physical status I - II undergoing elective open resection of colonic mass and anastomosis, PPV-based GGFM, a less invasive tool for intraoperative fluid management, might be a better option than CFM.