Using quilting sutures in decreasing seroma formation after managing large ventral hernias: a comparative study.

PURPOSE: The aim of this study was to evaluate using quilting sutures in a prospective randomized controlled manner the decrease in the incidence of seroma formation among patients subjected to ventral hernia repair. METHODS: The study was a prospective randomized controlled study. 370 patients with large ventral hernias were randomly distributed among two groups. Group A (control group) included 180 patients in whom the repair was done without quilting sutures. Group B (quilting group) included 190 patients, all performed with quilting. Method of dissection was unified as far as possible. All cases had an attached closed suction drain that was removed after two successive days of output ≤ 50 cc. The output of the suction drain was recorded; accumulation of clinically detected seroma after 1, 2 and 4 weeks of removal of the drain was monitored. RESULTS: There was no statistical difference between both groups as regards the demographic data and the hernia characteristics. There was significantly smaller amount of output of the drains in every day of the first five postoperative days as well as the total amount of the output before drain removal in favor of the quilting group. Drains were removed earlier in group B. The incidence of clinically detected seroma was less in group B as well. CONCLUSIONS: Quilting sutures is an effective and easy technique to reduce post-ventral hernia seroma accumulation.

Analysis of loco-regional and distant recurrences in breast cancer after conservative surgery.

BACKGROUND: A number of patients treated conservatively for breast cancer will develop loco-regional and distant recurrences. Our aim was to determine how their occurrence may be linked to the evolution of the disease. METHODS: We analyzed 238 women treated by conservative breast surgery and breast irradiation in a single institution. We evaluated the prognostic factors associated with loco-regional and distant recurrences and the prognostic value of local and regional recurrences on systemic progression. RESULTS: After a median follow-up of 5 year (range 1-10), 16 (6.72%) patients in the breast conservative surgery (BCS) groups had loco-regional recurrence. For distant recurrence, 10 (4.2%) patients had experienced distant recurrence. Lympho-vascular invasion (HR 2.55; 95% CI, 076 to 8.49) and an extensive intraductal component (HR, 2.22; 95% CI, 0.69 to 7.15) and nodal status are risk factors for loco-regional recurrence (LRR) after breast conservative therapy (BCT). Tumor size, nodal status, high histologic grade, and breast cancer diagnosed at a young age (≤35 years) are correlated with higher distant recurrence rates after BCT. CONCLUSIONS: Risk factors for LRR after BCS include lympho-vascular invasion, extensive inraductal component, and high nodal status, where as risk factors for distant recurrence include tumor size, nodal status, high histologic grade, and breast cancer diagnosed at a young age (≤35 years).

Renal leiomyoma.

Renal leiomyomas are rare benign tumours, which are usually small in size and incidentally discovered in most of cases. We report a case of giant renal leiomyoma encasing the right kidney in a 55 year old lady. We review the spectrum of features seen in reported leiomyomas on imaging and gross appearance. We discuss the differential diagnosis and highlight the fact that renal leiomyoma, although rare, must be considered in the differential diagnosis of spindle cell lesions of the kidney and that this tumour may present as a huge renal mass.

Devascularization procedure and DSRS: a controlled randomized trial on selected haemodynamic portal flow pattern in schistosomal portal hypertension with variceal bleeding.

OBJECTIVES: The use of duplex studies for the portal tree has revolutionized the concepts of haemodynamic pathophysiology in the case of portal hypertensive bleeders. The identification of possible haemodynamic patterns in schistosomal bleeders, and the effects of devascularization procedure and distal lienorenal shunts on a selected haemodynamic pattern, are the aim of this work. PATIENTS AND METHODS: Patients (219) with schistosomal hepatic fibrosis and history of bleeding oesophageal varices were studied. The patency, diameter, velocity and flow volume/min in the portal and splenic veins were followed by coloured Duplex. Two matched groups (30 patients each) with the most commonly found haemodynamic pattern (splenic vein flow exceeding portal vein flow) were operated upon. Devascularization procedure was done for the first group (A) and distal splenorenal shunt for the second group (B). RESULTS: Coloured duplex assessment of portal circulation in schistosomal patients identified four haemodynamic patterns. Pattern I (approximately 59%); splenic vein flow exceeds the portal vein flow. Pattern II (approximately 28%); portal vein flow exceeds splenic vein flow. In both patterns, the portal flow was hepatopedal. Patterns III and IV (8% and 5%, respectively) were associated with hepatofugal flow. Splenic vein flow exceeds portal vein flow in pattern III and the reverse in pattern IV. Distal lienorenal shunts done for patients with haemodynamic pattern I was followed by a rebleeding rate of 3.3% while devascularization done for patients with the same pattern was followed by a rebleeding rate of 26.6%. Mild encephalopathy was detected in 10% of patients with distal lienorenal shunts and responded to dietary regulations. CONCLUSIONS: DSRS proved to be ideal for schistosomal patients with hepatopedal flow and splenic vein flow exceeding portal vein flow; since in addition to eliminating the high splenic flow out of portal circulation, it decreased the pressure in the gastroesophageal region. Other patterns with their frequencies and the suggested surgical procedures were also presented.

Hepatic injuries: management and outcome.

A total of 52 patients with different grades of liver injuries were treated in a 1 year period: 32 patients had penetrating injuries and in 20 patients injuries resulted from blunt trauma. Blunt trauma victims were frequently associated with chest and head injuries and with skeletal fractures. A 4-fold incidence of associated intra-abdominal injuries was encountered in penetrating trauma victims. Blunt and gunshot victims commonly had severe grades of liver injuries (55% and 83.3%, respectively). Stab wounds caused simpler grades of injuries (86.7%). Suture hepatorraphy was the commonest procedure performed (57.7%).The other procedures applied to treat the injured liver were: selective ligation of the injured blood vessels (15.4%); packing (7.7%); and liver resection (3.8%). Two patients died on the operating table before any remedy was applied. The overall morbidity was 40.4%. The liver related complications constituted 17.3%. The total mortality was 13.5% and the liver related mortality was 9.6%.

Risk factors in surgery of gastroduodenal ulcer disease in patients with schistosomal portal hypertension.

The present study was conducted to determine the risk factors associated with surgical treatment of peptic ulcer disease (PUD) in patients with schistosomal hepatic fibrosis (SHF). The medical records of 32 patients treated at the Department of Surgery, Alexandria Faculty of Medicine between 1984 and 1994 were reviewed and data were analyzed. Twenty-five patients were male and seven were female, with a mean age of 43.3 +/- 24. Fifteen patients belonged to Child A and 13 to Child B. Twenty-one patients were variceal non-bleeders and 11 were bleeders. The ulcer was pyloric or duodenal in 30 patients and gastric in only two. Twenty-four patients were operated upon electively mostly for pyloric obstruction (n = 15) and eight patients emergently; five for perforation and three for bleeding. Hepatic insufficiency, renal function impairment and gastrointestinal bleeding were the most detrimental postoperative complications that occurred, either alone or in combination, in 13 patients (40.6%). Eight patients died (25%) of liver failure (n = 5), gastrointestinal bleeding (n = 2) and multiple systems organ failure (n = 1). Urgency of the operation and Child B were of significance for predicting mortality in contrast to age, sex, liver size, bleeding varices and ulcer location. Based on these data, it may be concluded that 1) operations for PUD in patients with schistosomal portal hypertension are expected to have high postoperative morbidity and mortality; 2) mortality rate significantly increases by emergency operations, presence of postoperative complications and in modified Child B patients; 3) Liver function must be optimized preoperatively; and 4) the most simple and expeditious procedure must be performed to minimize postoperative complications and hepatic decompensation.

Bilateral primary breast cancers: a clinicopathological study of the second primary.

Out of 2238 patients with breast cancer 35 developed carcinoma of the contralateral breast. Thirty-three developed metachronous tumours while two developed synchronous tumours. The thirty-five patients were followed up for periods between 4-8 years. The majority of patients belonged to the fourth decade and the peak incidence of developing a metachronous tumour occurred three to five years after diagnosis of the first primary. T2 lesions were the most frequent initial primaries and N1 lesions were commoner than N2. IDC was the commonest histopathological subtype. The overall two-year survival rate was 57.1% (20/35).