Clinical Association of CD44 Expression with Proliferative Activity and Apoptotic State in Egyptian Patients Suffering from Ulcerative Colitis and Colorectal Carcinoma.

BACKGROUND AND AIM: Cancer stem cell markers were thoroughly investigated as a promising strategy for the prediction of patient outcome and therapeutic response. The prospective role of CD44 cell adhesion molecule in tumorigenic potential and its association with the proliferative activity and apoptotic status of Egyptian patients with ulcerative colitis (UC) and colorectal cancer (CRC) were investigated in this study. MATERIAL AND METHOD: Flow cytometric analyses of CD44, DNA cell cycle, and apoptosis identified by Annexin V/PI were performed on colonic tissue specimens obtained from 44 CRC patients, 36 UC patients, and 30 controls. RESULTS: The CRC patients showed overexpression of CD44 marker (p < 0.0001) in comparison with UC and control groups. Regression analysis identified CD44 marker as an independent predictor for tumor staging and grading (p < 0.0001) of CRC patients. The CD44 expression was positively correlated with tumor stage (r = 0.656), tumor grade (r = 0.645), and the proliferative activity of DNA cell cycle (S phase, r = 0.396). However, CD44 expression was negatively correlated with early apoptosis (r = - 0.525). CONCLUSION: According to our findings, there was a significant and  positive association between CD44 dysregulated expression and S phase of DNA cell cycle but a negative association with early apoptosis in CRC patients, suggesting CD44 role in apoptosis suppression reducing the tumor growth reserve.

Comparative Study Between Laparoscopic Heller Myotomy Versus Pneumatic Dilatation for Treatment of Early Achalasia: A Prospective Randomized Study.

INTRODUCTION: Achalasia is an incurable primary motor disorder of the esophagus. The best treatment modality for achalasia is still controversial. This study compared the short- and intermediate-term outcome between endoscopic pneumatic dilatation (EPD) versus laparoscopic esophageal myotomy (LEM) for the management of adult patients with early-stage achalasia. PATIENTS AND METHODS: This was a prospective randomized controlled study of adult patients (20-50 years old) who presented with early-stage achalasia (esophageal diameter of <3.5 cm on contrast esophagography). Patients were classified into two groups according to the method of management: Group A patients were treated with LEM, whereas Group B patients were treated with EPD. Follow-up evaluations were conducted at 1 week, 3 months, 6 months, and then 1 year. RESULTS: In total, 50 patients were managed for a manometrically confirmed diagnosis of achalasia. The median age of presentation was 31.5 years, with a male-to-female ratio of 0.4:1. Both groups were comparable regarding patient demographics and preoperative severity of the condition. The rate of symptoms relief was 76% in EPD compared with 96% in LEM (P=.04). There was a significant lowering of lower esophageal sphincter in the LEM group (P=.0001). Perforation of the esophagus occurred in 8% of the patients during EPD, whereas mucosal tears occurred in 4% of the patients during LEM. Reflux symptoms developed in 28% and 16% of the patients in the EPD and LEM groups, respectively. CONCLUSIONS: LEM was more effective clinically and manometrically for patients with early-stage achalasia than EPD. There was no significant difference between the two procedures regarding complications.

Long term outcomes of choledochoduodenostomy for common bile duct stones in the era of laparoscopy and endoscopy.

BACKGROUND/AIMS: Choledochoduodenostomy (CDD) has been reported as an effective treatment of Common bile duct stones (CBDS). This study was designed to analyze short term and long term outcomes of CDD for CBDS. METHODOLOGY: Demographic data, preoperative, intraoperative and postoperative variables were collected. The long term assessment was done in a prospective manner included clinical examination, liver function, abdominal ultrasound, MRCP, upper GIT endoscopy and assessment of quality of life using Gastrointestinal Quality of Life Index (GIQLI). RESULTS: A total of 388 consecutive patients underwent CDD, the mean age was 57.92±13.25 years. The mean CBD diameter was 18.22±4.01 mm. The mean operative time was 81.21±20.23 minutes. Two patients had recurrent stone (0.06%) and managed successfully by endoscope. Gastritis was observed in 16.9% patients. No patient developed sump syndrome, deterioration in liver function or cholangiocarcinoma. Total and subgroup scores on the GIQLI before and after CDD differed significantly at follow-up (P=0.0001). CONCLUSION: CDD is a safe and effective method of drainage of CBD after clearance of CBDS. Long term outcomes are acceptable with good quality of life. Sump syndrome is extremely rare; CDD may be associated with mild to moderate gastritis. CDD doesn't lead to development of cholangiocarcioma.

Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study.

BACKGROUND: The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. METHODS: Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. RESULTS: One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. CONCLUSION: Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS. GOV ID: NCT02142517.

Pancreatic body hydatid cyst: A case report.

INTRODUCTION: Hydatid disease is a parasitic infestation caused by the cystic stage of Echinococcus granulosus. Hydatid cysts are commonly located in the liver and lung. Pancreatic affection by hydatid cysts is very rare even in endemic areas. PRESENTATION OF CASE: Our case is a 34-year-old male patient referred to our centre with a pancreatic body cyst diagnosed by abdominal CT scan. The patient gave 3 months history of epigastric pain. He also gave history of travelling to Saudi Arabia and China. His enzyme-linked immunoadsorbent assay (ELIZA) test for echinococcal antigens was positive. Surgical exploration revealed a 7cm cyst in the body of the pancreas separable from the surroundings. Endocystectomy and deroofing of the cyst was done. DISCUSSION: Due to its rarity and similarity with more common pancreatic cystic conditions, diagnosis of pancreatic hydatid cyst may be challenging. Abdmonial sonography and CT scan together with enzyme-linked immunoadsorbent assay (ELIZA) test for echinococcal antigens are helpful diagnostic tools. Therapeutic options include endocystectomy and deroofing, albendazol therapy with percutaneous drainage or laparoscopic excision of the cyst. CONCLUSION: Even in non-endemic areas, past history of travelling abroad in patients with pancreatic cystic lesions should raise the suspicion of hydatid disease as a possible diagnosis.

Outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease in non-responders to proton pump inhibitors.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common public health problem. Medical treatment remains the first line of treatment of GERD. Failure of medical treatment may occur in up to 45% of GERD patients. This study aims to evaluate the outcome of laparoscopic Nissen fundoplication (LNF) as a means of antireflux surgery in patients with poor response to anti-reflux medication. PATIENTS AND METHODS: This is a prospective study of patients who underwent LNF in the period between January 2000 and December 2010 in the Gastrointestinal Surgical Center, Mansoura University, Egypt. Patients were assessed preoperatively and postoperatively, after 1 year, by clinical examination, esophagogastroscope, barium esophagography, esophageal manometry and 24-h pH monitoring. Patient satisfaction after surgery was also graded through a questionnaire. RESULTS: The study population was 370 patients. 296 patients were good responders to proton pump inhibitors (PPI) while 74 patients were PPI non-responders. Preoperatively, atypical reflux symptoms were significantly more in PPI non-responders (P = 0.006). On follow-up, PPI responders significantly reported relief of heartburn (P = 0.01) and regurgitation (P = 0.04). Patient satisfaction was more in PPI responders (P = 0.04). Both groups were comparable regarding anatomical and functional assessment. Integrity of the wrap was higher in PPI responders (P = 0.04). CONCLUSION: PPI non-responders should not be precluded from LNF. Thorough assessment is mandatory to confirm GERD diagnosis. A substantial proportion of PPI failures show good response to LNF but significantly than clinical response in PPI responders. Increased likelihood of poor outcome after surgery should be discussed with the patient.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy.

AIM: To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis. METHODS: We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient's score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate. RESULTS: Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT. CONCLUSION: Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience).

BACKGROUND: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers. METHODS: This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS: A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m(2) (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture. CONCLUSIONS: Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.

Pancreatic cystic neoplasms: predictors of malignant behavior and management.

BACKGROUND/AIM: Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts. PATIENTS AND METHODS: Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed. RESULTS: Eighty-one patients had true pancreatic cyst. The mean age was 47 ± 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men (P = 0.04), older age (0.0001), cysts larger than 3 cm in diameter (P = 0.001), presence of solid component (P = 0.0001), and cyst wall thickening (P = 0.0001). The majority of patients with malignancy were symptomatic (26/28, 92.9%). The symptoms that correlated with malignancy included abdominal pain (P = 0.04) and weight loss (P = 0.0001). Surgical procedures were based on the location and extension of the lesion. CONCLUSION: The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst.

Laparoscopic Heller myotomy for achalasia: analysis of successes and failures.

BACKGROUND/AIMS: The outcome of laparoscopic myotomy for achalasia is dictated by many factors. METHODOLOGY: A retrospective study was conducted between 1997-2007, 58 patients who fulfilled all criteria for the diagnosis of achalasia underwent laparoscopic Heller myotomy and 45 (77.6%) were included. Mean follow-up period was 36±15 months; 56 patients had Dor fundoplication; 17 patients had been previously treated by pneumatic dilatation. All steps of the procedure, esophageal manometric findings and radiological records were analyzed to determine factors contributing to the clinical success or failure of the operation. The main outcome measure was swallowing status. RESULTS: Median hospital stay was 3±1 days and mean operative time was 75±20min. There were 7 intra-operative mucosal injuries; all sutured laparoscopically (5 had previous pneumatic dilatation). Good or excellent relief of dysphagia was obtained in 41 patients and was persistent among 2 patients (both had pneumatic dilatation preoperatively). The remaining 2 patients developed gastroesophageal reflux symptoms. These 41 patients had a preoperative smaller diameter of the esophagus (stage I, II and III), while those with guarding results (4) had stages III and IV. There was a decrease in LES pressure from 45±7mmHg to 10±2mmHg without evidence of restoration of esophageal peristalsis in any patient. CONCLUSIONS: Laparoscopic Heller myotomy with Dor fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. A good postoperative result is expected when the length of myotomy is adequate, LES pressure declines substantially, preoperative esophageal dilation is not excessive and distortion of the distal esophagus is absent.

Surgical management of gastric gastrointestinal stromal tumor: a single center experience.

BACKGROUND/AIM: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Our objective is to evaluate the outcome of surgical treatment of primary gastric GIST. MATERIALS AND METHODS: Between January 1997 and April 2008, thirty seven consecutive patients underwent resection for GISTs (35 patients with primary gastric GISTs and two patients with intestinal GISTs who were excluded from the study). These patients underwent upper endoscopy ± biopsy, barium meal and abdominal CT scan. Patients' demographics and clinical presentations were analyzed. Perioperative parameters measured included operative times, estimated blood loss, intraoperative finding, surgical techniques, morbidity and length of hospitalization. Recurrence and survival were also analyzed. RESULTS: Of the 35 patients with gastric GISTs included in the study, 63% were female. The median age was 59 ± 14 years (range, 23 to 75 years). The primary presenting symptoms were bleeding and dyspepsia; 43% of these tumors were located mainly in the body of the stomach. Tumor size was < 10 cm in 80% of the patients. The average tumor size was 6.3 ± 3.2 cm (range from 3 to 13 cm). Regarding the surgical management, 20 patients (57%) underwent gastric wedge resection, eight patients (23%) underwent partial gastrectomy and the remaining seven patients (20%) underwent total gastrectomy. Radical resections were found in 32 patients (91.5%) while palliative resections were found in three patients (8.5%). The resected lymph nodes were negative in 32 patients (91.5%). Recurrence was noted in three patients, with a median time to recurrence of 14.3 months (range, 7 to 28 months). The three- and five-years survival in patients who underwent wedge resection was 92% and 81%, respectively, where it was 95% and 87%, respectively, in patients who underwent gastrectomy (either partial or total). There were no major intraoperative complications or mortalities. CONCLUSION: Complete surgical resection either through wedge resection or gastrectomy with negative margins remains the gold standard treatment in the management of patients with primary resectable gastric GISTs.

Pelvic floor dyssynergia: efficacy of biofeedback training.

BACKGROUND AND STUDY AIMS: Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia (anismus). It is a behavioural disorder (no associated morphological or neurological abnormalities); consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback. PATIENTS AND METHODS: Sixty patients (35 females and 25 males) with a mean age of 30±12years and a 4year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions (colon-transit time, anorectal manometry, EMG and defaecography) were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of (6±2) sessions. RESULTS: At the end of sessions, 55 out of 60 patients (91.6%) reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions. CONCLUSION: Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia.

Functional outcome after Swenson's operation for Hirshsprung's disease.

BACKGROUND/AIM: Hirschsprung's disease (HD) is one of the most common causes resulting in lower intestinal obstruction in children with atypical clinical symptoms and inconspicuous morphological findings by barium enema X-ray. Recently, this situation has been largely ameliorated by improvement of instrument for measurement of anorectal pressure. By now, anorectal manometry has been regarded as a routine means for functional assessment and diagnosis of HD. It is accurate in nearly all cases of HD with characteristic absence of rectoanal inhibitory reflex. Different surgical modalities of treatment are available and Swenson's operation is one of the surgical procedures done for HD. Anorectal manometric findings may change after Swenson's operation with improvement of rectoanal inhibitory reflex in some cases. We aimed to evaluate functional results after Swenson's operation for HD using anorectal manometry. PATIENTS AND METHODS: Between 1996 and 2005, 52 patients were diagnosed with HD and operated upon by Swenson's operation in Gastroenterology Center, Mansoura University. There were 33 males (63.46%) and 19 females (36.54%) with a mean age of 3.29 +/- 1.6, (range 2-17 years). Anorectal manometry and rectal muscle biopsy were done preoperatively for diagnosis but after operation anorectal manometry was done after every six months and then yearly. RESULTS: All of the 52 patients showed absent rectoanal inhibitory reflex on manometric study with relatively higher resting anal canal pressure and within normal squeeze pressure. Postoperatively, there were 35 continent patients (67.31%) with 11 patients (21.15%) showing minor incontinence and six (11.54%) with major incontinence. On the other side, there were five patients (9.62%) with persistent constipation after operation (three due to anal stricture and two due to residual aganglionosis). Postoperative manometric study showed some improvement in anal sensation with the rectoanal inhibitory reflex becoming intact in six patients (11.54%) four years after operation. CONCLUSION: Anorectal manometry is a more reliable method for diagnosis of HD than barium enema X-ray but for final diagnosis, it is reasonable to combine anorectal manometry with tissue biopsy. Functional outcome after Swenson's operation for HD may improve in some patients complaining of incontinence or constipation. Anorectal manometry may show improvement of the parameters after Swenson's operation.

Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus.

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequlae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux (DGER) to endoscopic severity in patients with GERD and Barrett's esophagus. METHODS: Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to non-erosive reflux disease (NERD), erosive reflux disease (ERD) and Barrett's esophagus (BE). Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were done to all patients. RESULTS: Seventy one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed that 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux only, 18 (19.8%) had bile reflux only and 18 patients (19.8%) had no evidence of abnormal reflux. The percentage of the total time of bilirubin absorbance above 0.14, in 71 patients with ERD was (8.18 +/- 11.28%), and in 9 patients with BE was (15.48 +/- 30.48%) which was significantly greater than that in 11 patients with NERD (4.48 +/- 8.99%), p < 0.05 and p = 0.01 respectively. All BE patients had abnormal esophageal bile reflux (3 bile alone and 6 mixed bile and acid); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (13 bile alone and 31 mixed bile and acid); meanwhile 15 of them (21.2%) had abnormal acid exposure alone. Of the 11 patients with NERD, 4 patients (36.4%) had abnormal esophageal bile reflux, 2 of them mixed with acid. CONCLUSIONS: The Bilitec method reliably identifies the presence of bilirubin and quantitatively detects duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in GERD patients in this study. Bile reflux either alone or mixed with acid reflux contributes to the severity of erosive and non-erosive reflux disease as well as to Barrett's esophagus.

Quality of life and patient satisfaction 3 months and 3 years after laparoscopic Nissen's fundoplication.

BACKGROUND/AIM: This study is based on studying the quality of life and degree of satisfaction among gastroesophageal reflux disease (GERD) patients after Laparoscopic Nissen's fundoplication (LNF) operations. SUMMARY BACKGROUND DATA: A GERD patient is most interested in symptom relief, whereas his surgeon will also be interested in the improvement of anatomical and functional investigations. MATERIALS AND METHODS: One hundred patients with symptoms of GERD, adequate motility study and positive 24-hour pH studies underwent LNF in El-Mansoura Gastroenterology Center between 2002 and 2004. All patients completed the Gastroesophageal Reflux Disease-Health Related Quality Of Life (GERD-HRQL) questionnaire both pre- and postoperatively (early within 3 months after operation and late after 3 years). Furthermore, all patients were given a form with 4 grades (excellent, good, fair and poor) and they were requested to freely assess both the early and late clinical outcomes. RESULTS: There was statistically significant improvement in all the items of the GERD-HRQL questionnaire, both early and late (P < 0.001). With regard to patient satisfaction; only 58 cases showed excellent clinical satisfaction early postoperatively, while 29, 8 and 5 patients showed good, fair and poor responses, respectively. These figures improved on late followup (P < 0.05), i.e., 76 excellent, 16 good and 8 fair results. CONCLUSIONS: LNF improves all the items of quality of life among GERD patients significantly (P < 0.001). Patient satisfaction after LNF improves with time; 58 cases showed early postoperative excellent clinical satisfaction as compared to 76 late cases (P < 0.05). However, LNF may not be the standard management of reflux symptoms, particularly from some patients' perspective.

Outcome of pouch surgery for ulcerative colitis: single center experience.

AIM: The purpose of the present study is to present the experience and evaluate the outcome of pouch surgery for patients with ulcerative colitis (UC). METHODOLOGY: Fifty eight patients underwent surgery for UC between 1996 and 2007 at Mansoura Gastroenterology Center. A retrospective analysis has been done of all patients with UC undergoing surgery which includes details of the patient's history, indication of surgery, type of operation, postoperative morbidity, and functional outcome. RESULTS: The main indication for operation was failed medical treatment (n=42, 72.4%). Pouch surgery was performed in 25/58 patients (43.1%). The majority of patients, 23/25 (92%) had J-shaped pouch and most patients, 19 (76%), underwent a stapled anastomosis. Twenty patients (80%) had a defunctioning ileostomy. There was one postoperative death after pouch surgery. Early complications after pouch surgery included pelvic sepsis (n=4), small bowel obstruction (n=2), pouch hemorrhage (n=1), wound sepsis (n=3). Long-term follow-up data were available for 14 patients. The most common long-term complication was anastomotic stricture (n=9, 42.6%). Five patients (35.7%) presented with pouchitis. Median daytime stool frequency was 5.1. Three patients (21.4%) presented with fecal incontinence. CONCLUSION: Pouch surgery is a major one that attains many complications. However, the long term results and patient's satisfaction are reasonable.

Bile reflux measurement and its contribution to the severity of reflux esophagitis.

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequelae to pathological GERD. The aim of the study was to determine the contribution of acid and duodenogastroesophageal reflux to endoscopic severity in patients with GERD and Barrett's esophagus (BE). MATERIALS AND METHODS: Ninety-one patients complaining of reflux symptoms were studied with upper gastrointestinal endoscopy and graded to nonerosive reflux disease (NERD), erosive reflux disease (ERD) and BE. Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring (Bilitec 2000) were performed in all patients. RESULTS: Seventy-one patients (78.0%) had ERD (Savary-Miller (grade I-III), 11 patients (12.1%) had NERD and 9 patients (9.9%) had BE, which were suspected endoscopically and diagnosed by histological esophageal biopsy. Combined 24-h esophageal bilirubin and pH monitoring revealed the following: 39 patients (42.9%) had mixed acid and bile reflux, 16 (17.6%) had pathological acid reflux alone, 18 (19.8%) had bile reflux alone and 18 patients (19.8%) showed no evidences of abnormal reflux. The percentage of the total time of the bilirubin absorbance > 0.14 in 71 patients with ERD was (8.18+/-11.28%) and in 9 patients with BE was (15.48+/-30.48%), which was significantly greater than that in 11 patients with NERD (4.48+/-8.99%), P<0.05 and P=0.01 respectively. All the BE patients had abnormal esophageal bile reflux (bile alone (3 patients)); and mixed bile and acid (6 patients)); 44 of 71 patients (61.97%) with ERD had abnormal esophageal bile reflux (alone (13 patients) and mixed bile and acid (31 patients)); meanwhile, 15 of them (21.2%) had abnormal acid exposure alone. Despite 11 patients having NERD, four patients (36.4%) had abnormal esophageal bile reflux and two of them had mixed reflux of bile with acid. CONCLUSION: We believe that the Bilitec method reliably identifies the presence of bilirubin and quantitatively detects the duodenogastroesophageal reflux of bile. Mixed reflux (acid and bile) is the chief pattern of reflux in our GERD patients. Bile reflux either alone or along with acid reflux contributes to the severity of erosive and nonerosive reflux diseases as well as in BE.