The Role of C-reactive Protein and Procalcitonin in Predicting the Occurrence of Pancreatic Fistula in Patients who Underwent Laparoscopic Pancreaticoduodenectomy: a Retrospective Study.

The occurrence of postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD) is a significant concern, yet there is currently a lack of consensus on reliable predictive methods for this complication. Therefore, the aim of this study was to assess the clinical significance of C-reactive protein (CRP) and procalcitonin (PCT) values and their reliability in early predicting the development of clinically relevant pancreatic fistula (CRPF) following LPD.A retrospective analysis was conducted using data from 120 patients who had LPD between September 2019 and December 2021. Preoperative assessment data, standard patients' demographic and clinicopathological characteristics, intra- and postoperative evaluation, as well as postoperative laboratory values on postoperative days (PODs) 1, 3, and 7, including white blood cells (WBCs), CRP, and PCT, were prospectively recorded on a dedicated database. Two clinicians separately collected and cross-checked all of the data.Among 120 patients [77 men (64%), 43 women (36%], CRPF occurred in 15 patients (11 grade B and 4 grade C fistulas). The incidence rate of CRPF was 12.3%. A comparison of the median values of WBCs, PCT, and CRP across the two groups revealed that the CRPF group had higher values on most PODs than the non-CRPF group. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and cutoff values. It was discovered that POD 3 has the most accurate and significant values for WBCs, CRP, and PCT. According to the ROC plots, the AUC for WBCs was 0.842, whereas the AUC for PCT was 0.909. As for CRP, the AUC was 0.941 (95% CI 0.899-0.983, p < 0.01) with a cutoff value of 203.45, indicating a sensitivity of 93.3% and specificity of 91.4%.Both CRP and PCT can be used to predict the early onset of CRPF following LPD, with CRP being slightly superior on POD 3.

Histopathological and immunological study of rats liver hydatid cysts isolated from human, sheep, goat and cows.

In endemic places, liver hydatidosis is a life-threatening health issue. Many consequences such as hepatomegaly, infiltration with inflammatory cells and histopathological changes might arise as a result of liver hydatidosis. This study aimed to look into pathogenic changes in the livers of the rats that experimentally infected with hydatid cysts. These hydatid cysts were isolated from naturally infected humans, sheep, goats and cows. Liver hydatid cysts were collected from the main abattoir of Al-Muthanna province while human hydatid cysts were collected from Al-Hussein Teaching Hospital in Al-Muthanna province. The hydatid cysts were grossly and histology examined for inspection of hydatid cysts. The in vivo experiments were done by injection of hydatid protoscoleces or sand (fluid) in rats intraperitoneally. The results showed that the gross signs were same in all infected livers which range from paleness, hepatomegaly, hemorrhage and calcification. The hydatid cysts isolated from sheep and goat livers were highly fertile compared to others isolated from humans and cows. Injection of hydatid protoscoleces and hydatid fluid isolated from sheep and goat livers in rats induced the highest immune response compared to that isolated from humans and cows. The liver sections of rats that were injected with human, goat and sheep hydatid protoscoleces and fluids showed hyperplasia in the bile duct, aggregation nonnuclear cells with congested blood vessels. While liver sections of rats were received goat hydatid fluid, cow hydatid protoscoleces and hydatid fluid showed normal liver tissue. These findings suggested that the immunogenicity of hydatid materials is different according to the host and the component of hydatid cysts.

Non-Infectious Dermatological Manifestations among Patients with Diabetes Mellitus in Basrah, Iraq.

Diabetes mellitus (DM) is a clinical illness usually linked to a wide range of skin manifestations; however, skin, as the greatest organ in the body, has received little attention. As a result, this study aimed to detect the prevalence and pattern of non-infectious skin disorders among patients with diabetes. This study was carried out at the Faiha Specialized Diabetes, Endocrine, and Metabolism Center, Basrah Province, Iraq, from September 2020 to September 2021. The data were collected from 347 patients with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM). The exclusion criteria were patients with skin changes due to some medications, pregnancy, iatrogenic factors, skin infections, established hypo- or hyper-thyroidism, Cushing or adrenal insufficiency, pituitary disorders, end-stage renal impairment, malignancy, and established rheumatological disease and those who were on chemotherapy. Full dermatological examinations and screenings were performed under the supervision of a dermatologist expert and all clinically definable cutaneous lesions were recorded. The prevalence of skin lesions was estimated at 71.5% in patients. Pruritus, xerosis, acrochordon, diabetic dermopathy, acanthosis nigricans, and insulin-related lipohypertrophy were the commonest skin lesions reported among the patients. The occurrence of skin lesions in diabetic patients was proportional to the female gender, duration of disease, obesity, insulin therapy, and worse glycemic control. There was a broad spectrum of skin lesions in both T1DM and T2DM with corresponding prevalence.

Total Testosterone to Estradiol Ratio as a Predictor Marker of Metabolic Syndrome in Males.

Nowadays, metabolic syndrome (MetS) represents a global health challenge in developed and developing countries. The sex hormones disorders in males are related to many clinical co-morbidities. This study aimed to evaluate the total testosterone (TT) to estradiol (E2) ratio as a predictor marker of MetS. This case-control study included 88 MetS patients and 88 healthy individuals (control), in the age range of 18-69 years who were selected among patients who were referring to an outpatient clinic, using a convenience sampling method. The study participants were selected based on their medical history and physical examination, which included waist circumference, blood pressure, serum E2, TT, fasting blood glucose (FBG), triglyceride (TG), and high-density lipoprotein-cholesterol (HDL-C). Diagnosis of MetS was confirmed according to the National Cholesterol Education Program Adult Treatment Panel III guidelines. The findings revealed that the mean TT level was significantly lower among patients with MetS (P<0.001), while the mean E2 level was significantly higher among patients with MetS (P<0.001). The mean TT to E2 ratio was significantly lower among patients with MetS (OR=9.6, P<0.001). There was a significant correlation between MetS components and TT to E2 ratio and waist circumference (WC) (r = - 0.49, P<0.0001). The means of weight, WC, blood pressure, and FBG levels were significantly higher in patients with MetS (P<0.001, P<0.001, P<0.001, P=0.04, respectively), and the lipid profile of patients with MetS was abnormal (TG, P<0.001, HDL-C, P<0.001). Eventually, it can be concluded that the TT to E2 ratio can be regarded as a significant predictor of MetS in males.

Preclinical Experiments for Hypospadias Surgery: Systematic Review and Quality Assessment.

Background: There is a steadily growing number of different reconstructive surgical procedures for hypospadias that were tested on animal models prior to their human application. However, the clinical translatability and reproducibility of the results encountered in preclinical urethral reconstruction experiments is considered poor, with significant factors contributing to the poor design and reporting of animal experiments. Our objective was to evaluate the quality of the design and reporting in published articles of urethral reconstructive preclinical studies. Methods: Both PubMed and EMBASE databases were searched for animal urethral repair experiments between January 2014 and September 2019. Internal quality (bias) was evaluated through several signaling questions arising from the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE), while the quality of reporting was assessed by the Animal Research: Reporting of In vivo Experiments (ARRIVE) guidelines by scoring of a 20-item checklist. Results: A total of 638 articles were initially screened after the literature search. Employing the inclusion and exclusion criteria, 30 studies were chosen for full-text screening and 21 studies were considered eligible for the quality assessment. The mean score of the checklist was 66%. The elements that accomplished the highest grades included the number of animals utilized, the number in each investigational and control group, and the delineation of investigational conclusions. The items that were least commonly stated comprised information about the experimental method, housing and husbandry, rationalization of the number of animals, and reporting of adverse events. No paper stated the sample size estimation. Conclusion: We found that several critical experiment design principles were poorly reported, which hinders a rigorous appraisal of the scientific quality and reproducibility of the experiments. A comprehensive implementation of the ARRIVE guidelines in animal studies exploring urethral repair is necessary to facilitate the effective translation of preclinical research findings into clinical therapies.

Long-term fate of the incised urethral plate in Snodgrass procedure; A real concern does exist.

We present here a case of a patient post tabularized incised plate urethroplasty for distal hypospadias without chordee who developed urethral stenosis and acquired curvature along the territory of the incised plate necessitating a redo surgery. The histological analysis of the incised urethral plate revealed absence of smooth muscles, vessels and elastin fibers within the area of the incised plate which could explain the poor compliance of this segment and the development of the curvature. To our knowledge, this case is the first in humans displaying the long-term histological findings of healing post tabularized incised plate urethroplasty.

"Double-Lumen Valve-Controlled Intra-Operative Pyeloplasty Stent (VIPs)": A New Technology for Post-Pyeloplasty Stenting - Proof of Concept Study in a Preclinical Large Animal Model.

BACKGROUND: Pyeloplasty is a common surgical operation with a high success rate. However, significant challenges are to be optimized in the design of stenting systems in order to improve perioperative monitoring of urine drainage and enhance patient and family comfort through easier post-operative care. MATERIALS AND METHODS: In a preliminary study in six pigs, handling, mechanical and functional features of this stent system were tested. In our main study, six double-lumen stents (230 mm long each) and 6F/9F external diameter were implanted through the ureteric walls of six domestic pigs to allow postoperative drainage and monitoring following ureteroureterostomy. After a 7-day survival period, monitoring with intravenous antibiotic coverage, and pain control, contrast antegrade pyelogram, under valve control, and renal ultrasonography were conducted and stents explanted and the animals were then euthanized. RESULTS: The double-lumen valve-controlled stent supported the healing of the neo anastomoses and helped to monitor perioperative urine drainage and perianastomotic leakage accurately. It also guided a well-controlled more informative radiological contrast-supported imaging before removal of the stents that confirmed the healing of the neo anastomotic site and no leak formation. The double-lumen system demonstrated high feasibility regarding its insertion, functionality, and removal capacities. The excellent flexibility of the individual stents allowed exact anatomically controlled implantation. CONCLUSION: The double-lumen valve-controlled stent system was studied in a porcine model, which demonstrated its feasibility. Preclinical experience revealed favorable results concerning stent implantation, operability and functionality, in the perioperative management of pyeloplasty or ureteric surgery.

Suspected testicular torsion in children: diagnostic dilemma and recommendation for a lower threshold for initiation of surgical exploration.

PURPOSE: Testicular torsion (TT) represents a clinical challenge that needs emergency surgical assessment. It is common to have negative scrotal exploration due to confounding symptoms and signs which makes it sometimes difficult to differentiate from similar surgical emergencies that do not warrant surgery. At the same time, several occasions of misdiagnoses or late interventions occur with devastating effects. We aim at delineating the significance of the different clinical, laboratory, and radiological variables in the detection of TT. METHODS: We retrospectively reviewed the charts of 52 patients who were surgically explored with a preoperative working diagnosis of suspected TT in our center over the period from 2011 to 2015. All the patients were examined by pediatric surgeons in the emergency room and had undergone ultrasound imaging of the testes. The ultrasound images were retrospectively reviewed by a pediatric radiologist who was blinded to the intraoperative findings. Univariate and multivariate and logistic regression analyses were performed. RESULTS: Of the studied group of patients, the majority (84.6%) had TT upon surgical exploration. The most frequently presented symptom was pain (80.8%), and only a minority (11.5%) presented with vomiting. Radiological findings with the highest sensitivity were heterogeneous echogenicity in favor of TT and enlarged epididymis indicating that TT is unlikely. However, the predictability of TT by any of the assessed clinical and imaging factors was statistically insignificant. CONCLUSION: It is important to gather all relevant data from clinical, laboratory, and imaging sources when assessing pediatric patients with suspected TT given the inaccuracy of each single one of them if used alone. Keeping this in mind, Doppler ultrasound has a significant role to aid in the accuracy of the diagnosis and hence the appropriate decision-making thereafter. However, we found no single clinical or imaging sign that is sensitive enough to prove or rule out TT. Therefore, surgical exploration should take place in a timely manner. Moreover, further research is necessary to construct scoring systems where different predictors collectively have higher reliability.

Production of functional spreadable processed cheese using Chlorella vulgaris.

BACKGROUND: Chlorella vulgaris alga is one of the most important additives for enhancing the nutritional content of conventional foods, hence positively affecting human health. This alga is known as a rich source of protein, fatty acids, fiber, essential vitamins and minerals. Also, it contains antioxidants, omega 3, antivi- ral and anticancer properties. The aim of this research is increasing the nutritional and potential therapeutic value of processed cheese by using Chlorella vulgaris alga, taking advantage of its high nutritional and health value. METHODS: The ingredients in the processed cheese blends were mature cheddar cheese, Ras cheese, butter, skimmed milk powder, Emulsifying salts (K-2394, S9s & S4), Chlorella vulgaris (in freeze- dried and slurry forms). Chemical, rheological and sensory evaluation properties were evaluated in processed cheese analogue (PCA) treatments when fresh and after three months of cold storage at 5–7°C. PCA treat- ments were enriched with 2%, 4% and 6% dried Chlorella vulgaris powder in the cheese blends and 4% Chlorella vulgaris slurry. RESULTS: The incorporation of alga into processed cheese led to an increase in their functional characteristics. The results of sensory evaluation of PCA samples demonstrated that 2% of alga addition was the best treat- ment, followed by 4%, but that the level of 6% was unacceptable to consumers. The studied alga enhanced the cheese analog with the high levels of selenium, zinc, iron, magnesium and potassium. Antioxidant activity in the cheese enhanced with Chlorella vulgaris was higher than the control sample. To improve some proper- ties of PCA, other emulsifying salts (S9S and S4) were tested and the alga was added in the form of slurry with value of 4% into the cheese blend. Both S9S and S4 emulsifying salts were good and the S4 was the best for oiling off and meltability. Also, when using the slurry of Chlorella vulgaris, the granular texture of the cheese analog completely disappeared. CONCLUSIONS: The results showed that the alga indeed increased nutrition values and health benefits to the processed cheese, making it a substantial functional food. Therefore, we recommend supporting the manu- facture of the processed cheese analogue with the addition of 2% Chlorella vulgaris alga in soft powder form and 4% Chlorella vulgaris alga in slurry form at the end of the processing.

Urethral Meatus and Glanular Closure Line: Normal Biometrics and Clinical Significance.

Purpose: The aim of this study is to explore the normal external urethral meatal and glans closure line in normal boys, and to investigate the correlation between these glans biometrics and the age of the participants. MATERIAL AND METHOD: 103 male children were asked to participate in the study during ritual circumcision. Par-ents of 94 of them (mean age 5.9 years, range 0.6-13) accepted while remaining 9 did not. Glans biometrics were measured using digital calipers. RESULT: 100% of the study participants had a vertical slit-like meatal opening located at the tip of the glans. The length of the meatal opening was 5.3 (± 1) mm and of ventral glans closure was 4.8 (±1.1) mm. Significant cor-relation between both the external meatal opening and closure lines lengths and age was observed. Moreover, the meatal opening size was correlated to the glans closure line as well (r = 0.36, confidence interval 0.14-0.54, P < .001). CONCLUSION: The site and size of the meatus opening in normal male children is consistent, and ventral glans clo-sure is equal to or slightly less than meatal length. These findings could aid in glanular reconstruction configuration during hypospadias surgery.

Visceral basidiobolomycosis: An overlooked infection in immunocompetent children.

Visceral basidiobolomycosis is an unusual fungal infection of viscera caused by saprophyte Basidiobolus ranarum. It is very rare in healthy children and poses a diagnostic challenge due to the non-specific clinical presentation and the absence of predisposing factors. We report a case of gastrointestinal basidiobolomycosis in a 4-year-old healthy girl who presented with a short history of abdominal pain, bleeding per rectum, fever, and weight loss. The diagnosis was based on high eosinophilic count, classical histopathology findings of fungal hyphae (the Splendore-Hoeppli phenomenon), and positive fungal culture from a tissue biopsy. Fungal infection was successfully eradicated with a combined approach of surgical resection of the infected tissue and a well-monitored course of antifungal therapy. The atypical clinical presentation, diagnostic techniques, and the role of surgery in the management of a rare and lethal fungal disease in an immunocompetent child are discussed.

Complicated Amyand's Hernia in a Neonate.

Amyand's hernia is a rare clinical entity in which the vermiform appendix is present within the inguinal hernia sac. Here, we report a 5-day-old neonate with dysmorphic features referred to us with a tender irreducible right inguino-scrotal swelling. Surgical exploration showed gangrenous appendix with a peri-appendicular abscess in the inguinal hernia sac. Appendectomy and right herniotomy was performed.

Role of laparoscopy in non-trauma emergency pediatric surgery: a 5-year, single center experience a retrospective descriptive study with literature review.

BACKGROUND: Although laparoscopy is rapidly becoming the abdominal surgical modality of choice in adults, there are obstacles to its use in children. We analyzed our experience with pediatric laparoscopic surgery over the past 5 years, with particular emphasis on emergency procedures. FINDINGS: We retrospectively evaluated the records of patients aged <14 years who had undergone laparoscopic procedures for non-trauma emergency conditions at our institution from January 2006 to December 2010. The clinical parameters evaluated included operation time, total length of hospital stay, and postoperative complications.During the 5-year study period, 482 laparoscopic procedures were performed on patients aged <14 years, comprising 300 emergency and 182 elective operations. The majority of procedures were laparoscopic appendectomies, with most of the others being resections of ovarian cysts or Meckel's diverticulae, or adhesiolyses. We observed an improvement in outcomes over the 5-year period, as shown by shorter operation times and shorter postoperative hospital stays. The numbers of laparoscopic procedures performed increased over time. CONCLUSIONS: Pediatric laparoscopic surgery for emergency conditions provides excellent results, including better exposure and cosmetic outcomes than laparotomy. At our institution, the numbers and types of laparoscopic procedures performed have increased over time, and the outcomes of laparoscopic procedures have improved.

Laparoscopic management of intra-abdominal testis: 5-year single-centre experience-a retrospective descriptive study.

Background. Undescended testis is one of the most common urological problems in children, affecting about 1% of boys at age of 1 year. Of these, about 20% have a nonpalpable testis with a very high probability that the testis is absent. This may have a significant impact on the possibility of malignancy in these testes, as well as on the later fertility of these subjects. Methods. We retrospectively analyzed the demographic and clinical findings, as well as immediate and 6-month outcomes, in 91 patients diagnosed with impalpable undescended testes between January 2006 and December 2010. Results. Of the 91 patients, 9 had bilateral and 82 had unilateral impalpable testes. All 100 testes were managed laparoscopically. The largest group of intra-abdominal testes in this series, 42 testes, was entering the internal ring; in these, laparoscopic exploration and standard open orchiopexy resulted in a 66% success rate. The total success rate was 63.3%. Conclusion. Laparoscopy is extremely useful in both the diagnosis and treatment of impalpable testes. Objectively measured mobility of the testis towards the contralateral internal inguinal ring is an excellent intraoperative indicator for type of orchiopexy. Standardization of management may increase the success rate of orchiopexy.

Congenital diaphragmatic hernia: a modern day approach.

Centralization of all complicated congenital diaphragmatic hernias (CDH) was organized in Germany from 1998, collecting 325 consecutive patients with striking increasing survival rates. This series report 244 patients from 2002 to 2007. Today, large defects are detected early in pregnancy by ultrasound and magnetic resonance imaging (MRI). In extracorporeal membrane oxygenation (ECMO) patients, prenatal lung head ratio (LHR) was 1.2 (median) at the 34th week of gestation or less than 25 ml lung tissue in MRI. This means that all patients below LHR of 1.4 should be transferred prenatally in a tertiary center. High risk group for survival was defined as LHR below 0.9, ie, 10 ml in MRI planimetry. Inborn patients show better results than outborns. In algorithm therapy, gentle ventilation plays an important role in preventing damage to the lung tissue and avoiding long term ventilation. When PaCO(2) was more than 75 mmHg, ventilation was changed to high frequency oscillatory ventilation (HFOV). Indication for ECMO was seen in preductal PaO(2) less than 50 mmHg over 2-4 h or less than 40 mmHg over 2 h. ECMO related risks included intracerebral bleeding (9%), intrapulmonary bleeding (14%), and convulsions (16%). Surgically, a longitudinal midline incision for exposure of the defect, the duodenal kinking, and probably for abdominal patching was perfect. A cone formed goretex patch provided more abdominal space and reduced abundant intrathoracical cavity. No drain was used. Postoperative complications were described. Overall survival in 244 consecutive patients was 86.5% for all patients born alive. All those who needed ECMO survived in 71%, underlining ECMO as a treatment of last choice. Follow-up for quality of life after CDH is described.

Predictors and frequency of conduction disturbances after open-heart surgery.

INTRODUCTION: The risk of developing conduction disturbances after coronary bypass grafting (CABG) or valvular surgery has been well established in previous studies, leading to permanent pacemaker implantation in about 2% to 3% of patients, and in 10% of patients undergoing repeat cardiac surgery. We sought to determine the incidence, features and predictors of conduction disorders in the immediate post-operative period of patients subjected to open-heart surgery, and the need for permanent pacemaker implantation. MATERIAL AND METHOD: We prospectively studied 374 consecutive patients who underwent open-heart surgery in our institution: coronary artery bypass (CABG) (n=128), Mitral valve replacement(MVR)(n=18), aortic valve replacement(AVR) (n=21), MVR and AVR(n=56), repair of ventricular septal defect (VSD) (n=51), repair of tetralogy of Fallot (TOF) (n=57),CABG and valvular surgery (n=6), others (n=37). RESULTS: Among 374 patients included in our study (mean age 34.46+/-25.68; 146 males), 192 developed new conduction disorders: symptomatic sinus bradycardia in 8%, atrial fibrillation with slow ventricular response (AF) in 4.5%, first-degree atrioventricular block (AVB)in 6.4%, second-degree AVB in 0.3%, third-degree AVB in 7%, new right bundle branch block (RBBB) in 33%, and new left bundle branch block (LBBB) in 2.1%. In 5.6% patients, a permanent pacemaker was implanted, 47.6% of them underwent valvular surgery. In 44.1% of patients the conduction defects occurred in the first 48 hr. after surgery. In CABG group, 29.7% of patients developed new conduction disturbances; the most common of them was symptomatic sinus bradycardia. After valvular surgery 44.2% of patients developed conduction disturbances, of those the most common was atrial fibrillation with slow ventricular response . After VSD and TOF repair, the most common conduction disturbance was new RBBB. Perioperative myocardial infarction (MI) occurred in 1.9% of patients. The occurrence conduction disturbance was compared with patient age, sex, occurrence of perioperative MI, ejection fraction (EF), postoperative use of ss-adernergic receptor blocking agents and digitalis and type of cardiac surgery. By regression analysis there was a correlation between type of surgery and new conduction defects, being significant for CABG and TOF repair. Only the occurrence of perioperative MI was related to PPM implantation. CONCLUSION: Irreversible AVB requiring a PPM is an uncommon complication after open-heart surgery. Peri-operative MI is a risk factor.