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Introduction: Endoscopic ultrasound (EUS)-guided pancreatic cysto-gastrostomy/duodenostomy is the current accepted practice for management of symptomatic pancreatic pseudocysts with insertion of two or more double-pigtail (DP) stents. There is no much work on the efficacy of using a single wide-caliber DP stent, aiming to decrease the time, complications, and accessories used in the procedure. Aim of the Work: The aim of this study was to assess technical and clinical outcomes of using a single wide-caliber DP stent in EUSguided pancreatic pseudocyst drainage. Methodology: This multicenter prospective study included 57 patients, from which the 35 patients with symptomatic pancreatic pseudocysts enrolled. Patients with cysts with multiple septations (7 cases) or cyst with >30% necrosis (8 cases) of the cyst content and patients with generalized ascites (4 cases) or patients with major comorbidities (3 cases) were excluded. Patients were followed up within 1 month and 6 months after stent placement to assess complete resolution or a decrease in the sizes of cysts with clinical symptomatic improvement. Results: From 57 patients, 35 patients (19 females/16 males, median age 40 years) with a symptomatic pancreatic pseudocyst were referred for EUS-guided drainage. All used stents were 10 Fr DP plastic stents. The median duration of the whole procedure was 16 min. Technical success was achieved in all cases. Clinical success was encountered in 32 patients (91.4%) without re-accumulation on follow-up. Minor adverse events were encountered in 3 patients (8.6%) including post-procedure abdominal pain (1 case) and fever (2 cases). Conclusion: We suggest that using a wide-caliber single-pigtail stent for EUS-guided cystogastrostomy is safe and effective with short procedure time, with reduced risks from the insertion of another stent(s).

Background Accurate rectal tumor staging guides the choice of treatment options. EUS and MRI are the main modalities for staging. Aim of the work To compare the performance of EUS and MRI for loco-regional staging of anorectal cancer after neo-adjuvant therapy. Methods Seventy-three (37 male, 36 female) patients with rectal cancer after neo-adjuvant chemoradiotherapy were enrolled. Histopathological staging after surgery were used as reference for comparing the yield of loco-regional staging for EUS and MRI. EUS and MRI were done 1 month after completion of neo-adjuvant therapy. Results Regarding post-surgical T staging, eight patients had early tumor (T2 = 16 and T1 = 9) and thirty six were locally advanced (T3 = 36), while N staging, forty patients with negative nodes and 33 were positive (N1 = 22 and N2 = 11). Comparing EUS to MRI, it showed a higher sensitivity (95.7% vs. 78.7%), specificity (84.6% vs. 68.0%) and accuracy (91.8% vs. 75.3%) for staging early and locally advanced tumor. Also, it had a higher sensitivity (78.8% vs. 69.7%), specificity (75.0% vs. 65.0%) and accuracy (76.7% vs. 67.1%) for detection of lymph nodes. Conclusion EUS appears to be more accurate than MRI in loco-regional staging of rectal carcinoma after neo-adjuvant therapy.

Background Hepatitis C virus (HCV) infection is a major cause of liver-related morbidity and mortality among thalassemic patients. Direct-acting antiviral agents (DAAs) are highly effective and well-tolerated by chronic HCV patients. Results The mean age of our patients was 29 years. Sustained virologic response (SVR) at 12 and 24 weeks was achieved in all patients (100%). The most common side effects were fatigue (18%), anemia (13.63%), and headache (4.5%). There was no statistically significant difference in the hemoglobin level before and after treatment (p = 0.48). There was a significant improvement in serum bilirubin and mean ALT levels after treatment compared to baseline data (p Conclusions DAAs, namely, sofosbuvir plus daclatasvir or sofosbuvir plus ledipasvir, are effective and well-tolerated regimens in thalassemic patients with chronic HCV.

Background and study aims Unexplained biliary dilatation (UBD) frequently represents a diagnostic dilemma. Linear endosonography (EUS), with its close proximity to the pancreaticobiliary system and the ability for tissue acquisition, could have a role in revealing etiologies of UBD particularly in the context of negative other non-invasive modalities. However, in such patients, the decision for this semi-invasive procedure is usually debatable and often needs justification. Thus, we aimed to evaluate the diagnostic utility of linear EUS in patients with UBD after negative magnetic resonance cholangiopancreatography (MRCP) and to delineate predictors for EUS ability to detect neoplastic lesions. Patients and methods This was a prospective diagnostic observational study between 2018 and 2021. Included patients with evidence of biliary dilatation on abdominal ultrasound and negative MRCP underwent linear EUS examination. Results were compared to the final diagnosis relied on histopathology after EUS-guided biopsy or surgery for neoplastic lesions, while ERCP, diagnostic EUS criteria plus histopathology for autoimmune pancreatitis, Rosemont criteria for chronic pancreatitis, and/or follow-up for 6 months were the gold standard tests for non-neoplastic etiologies. Logistic regression was conducted to reveal predictors of neoplasm detection by EUS. Results Sixty-one patients (mean age 60 years, 32 females) were enrolled; 13.1% of them were asymptomatic. The final diagnosis was categorized into 29 patients with and 32 without neoplasms. Sensitivity, specificity, positive, negative predictive values (PPV, NPV), and accuracy of EUS-positive findings were 98.3%, 100%, 100%, 66.7%, and 98.3%, respectively. Corresponding results for neoplasm identification were 100%, 93.8%, 93.5%, 100%, and 96.7%, respectively. The most common neoplastic etiologies were small pancreatic and ampullary masses. Common bile duct (CBD) diameter > 12.9mm and CA19-9 > 37.1 u/ML were independent predictors for pancreaticobiliary neoplasm at multivariate regression analysis. Conclusion Linear EUS appears to have a high accuracy in detecting etiologies of UBD, with higher sensitivity for small pancreatic, ampullary lesions, and CBD stones. CBD diameter > 12.9 mm and elevated CA19-9 > 37.1 u/ML should raise a concern about the presence of occult pancreaticobiliary neoplasm, and then, EUS may be warranted even in asymptomatic patients.

Background and study aim: The treatment of chronic hepatitis C infection (CHC) has been revolutionized by using novel direct-acting antivirals (DAAs). Transient elastography (TE) and aspartate aminotransferase to platelet ratio index (APRI) are simple and convenient diagnostic tools for the assessment of liver fibrosis. This study was designed to evaluate liver fibrosis by using TE and APRI before and one year after a full course of DAAs therapy in cases with CHC infection. Patients and methods: TE and APRI were measured before treatment and one year after a full course of DAAs therapy in a prospective study of 82 CHC cases. All candidates with CHC infection were genotype 4. TE was measured by Fibroscan and liver stiffness measurement (LSM) was considered reliable if 10 successful LSM had been obtained with a success rate (SR) ≥ 60% and interquartile range (IQR)

Background Transarterial chemoembolization (TACE), a locoregional therapy, is widely recommended as first-line treatment for intermediate-stage hepatocellular carcinoma (HCC). Several prognostic indices have been used to predict overall survival in HCC patients undergoing the procedure. Patients and methods A total of 73 patients with HCC, candidate for TACE attending to HCC clinic, Specialized Medical Hospital, Mansoura University, were subjected to full history taking, physical examination, laboratory profile and testing for interleukin (IL)-10 and tumor necrosis factor (TNF)-α polymorphisms. Aggressiveness index is calculated for all patients and followed-up for 4 weeks after TACE to asses response. According to IL-10 and TNF-α polymorphisms results, patients were divided into groups and compared. Results The aggressiveness index is significantly higher in the TT/AT haplotype of IL-10 and GG haplotype of TNF-α in comparison with the other haplotypes. The TT/AT haplotype of IL-10 and GG haplotype of TNF-α are significantly associated with less favorable outcome after TACE, wherein 64.3 and 56.25% of patients showed residual active tumor tissue, respectively. Conclusion The TT/AT haplotype of IL-10 and GG haplotype of TNF-α are associated with more aggressive pattern of HCC and less favorable outcome after TACE; hence, these patients must be treated as early as possible.

Background The stage of liver fibrosis is the most important predictive factor for initiation and duration of antiviral treatment, where patients with early fibrosis stages respond to treatment better with a higher sustained virologic response rate. Several noninvasive tests to stage the degree of fibrosis in patients with chronic hepatitis C virus (HCV) infection have been used. No single test is known to have high accuracy and the results of each test must be carefully interpreted. The objective of the study is to evaluate the value of serum fibronectin (FN) as a noninvasive predictor for the assessment of HCV-induced liver fibrosis. Patients and methods A total of 100 patients with chronic HCV infection proved by HCV antibodies and HCV RNA preparing for antiviral treatment were exposed to full history, physical examination, and laboratory assessment. Serum FN level and fibroscan were done for all patients. According to the results of fibroscan, the patients were divided into four groups of liver fibrosis and compared. Results All patients were proved to have HCV viremia with average PCR of 1990.52±3144.29 copies/ml. A statistically significant difference was found as regards FN, fibroscan, and APRI score between patients with fibrosis in comparison to patients without fibrosis. According to fibroscan results, 20 patients were found with fibrosis stage 0, 24 patients with stage 1, 24 patients with stage 2, eight patients with stage 3, and 24 patients with stage 4 (cirrhosis). On comparison of different stages of fibrosis as regards FN level, we found no statistically significant difference between stages. FN have a sensitivity of 67.5% and a specificity of 47.4% with 84.4% positive predictive value. Conclusion FN is a good noninvasive marker for the assessment of liver fibrosis in patients with chronic HCV. Larger scale multicenter studies are needed to assess its validity in the detection of fibrosis caused by causes other than HCV.

Background Hepatocellular carcinoma (HCC) is the commonest primary liver neoplasm that usually develop in the background of cirrhosis. Hepatitis C virus is endemic in Egypt and is the major cause of cirrhosis. Studying the characteristics of patients with HCC may help in clarifying the schedule for screening of high-risk patients for an early detection of HCC. Patients and methods The 492 patients attending the hepatology and HCC clinics in Specialized Medical Hospital, Mansoura University for follow up of liver cirrhois and HCC were subjected to full history, physical examination, laboratory profile, and imaging studies needed for the diagnosis. Data were collected and analyzed. According to the radiological results, patients were divided into three groups (fibrosis, cirrhosis, and HCC) and compared. Results The study included 336 males and 156 females. Patients with HCC were mainly males with a mean age of 58 years. A statistically significant difference between HCC group and the other groups with respect to hemoglobin level, white blood cells count, platelet count, aspartate aminotransferase, alanine aminotransferase, albumen level, serum bilirubin, international normalized ratio, and α-fetoprotein (AFP) was found. The sensitivity and specificity of AFP in differentiating HCC cases are 81.1 and 71.9%, respectively. Logistic regression for prediction of HCC showed that males with age greater than 58 years, hypoalbuminaemia, and AFP greater than 11.2 ng/dl have a 76.3% positive predicted value. Conclusion Cirrhotic patients with age greater than 58 years, males, hypoalbuminaemia, and AFP greater than 11.2 ng/dl are at a higher risk to develop HCC more than other patients and should be monitored at close quarters with better contrast-enhanced technique either contrast-enhanced ultrasound or computed tomography scan.

Introduction and aim. Transient elastography is gaining popularity as a non-invasive method for predicting liver fibrosis, but inter observer agreement and factors influencing reproducibility have not been adequately assessed.Material and methods. This cross-sectional study was conducted at Specialized Medical Hospital and the Egyptian Liver Foundation, Mansoura, Egypt. The inclusion criteria were: age older than 18 years and chronic infection by hepatitis C. The exclusion criteria were the presence of ascites, pacemaker or pregnancy. Three hundred and fifty-six patients participated in the study. Therefore, 356 pairs of exams were done by two operators on the same day.Results. The overall inter observer agreement ICC was 0.921. The correlation the two operators was excellent (Spearman’s value q = 0.808, p < 0.001). Inter-observer reliability values were κ = 0.557 (p < 0.001). A not negligible discordance of fibrosis staging between operators was observed (87 cases, 24.4%). Discordance of at least one stage and for two or more stages of fibrosis occurred in 60 (16.9%) and 27 cases (7.6%) respectively. Obesity (BMI ≥ 30 kg/m2) is the main factor associated with discordance (p = 0.002).Conclusion. Although liver stiffness measurement has had an excellent correlation between the two operators, TE presented an inter-observer variability that may not be negligible.

Transient elastography (TE) is gaining popularity as a non-invasive method for predicting liver fibrosis. The practical utility of the method is based on establishing cutoff values for each stage of fibrosis. A diagnosis of stage is based on measurements of liver stiffness that vary in different studies. The present study aimed to establish cutoff values for each stage of fibrosis to assess the performance of TE in fibrosis staging in Egyptian chronic HCV patients. This cross-sectional study was conducted at Specialized Medical Hospital and the Egyptian Liver Foundation, Mansoura, Egypt. The inclusioncriteria were: age older than 18 years and chronic infection by hepatitis C. The exclusion criteria were the presence of ascites, pacemaker or pregnancy. Three hundred and fifty six consecutive patients with chronic hepatitis C participated in the study. Liver fibrosis was staged according to the METAVIR system. The AUROCs for F2 or greater, F3 or greater and cirrhosis (F4) were 0.91 (95% CI 0.87 to 0.94), 0.95 (95% CI 0.91 to 0.99) and 0.97 (95% CI 0.96 to 0.99), respectively. ROC curve analysis identified optimal cutoff value of liver stiffness measurements as high as 9.8 kPa for F ≥ 2, 10.4 kPa for F ≥ 3, and 17.2 kPa for F = 4. The overall relation between fibrosis stages when comparing both FibroScan and biopsy was significant agreement between both (the kappa measure was 0.430 and p

Context: Hepatitis C virus (HCV) is both hepatotropic and lymphotropic. Chronic HCV infection has been associated with extrahepatic manifestations, especially lymphoproliferative disorders. Follicular lymphoma (FL) is the most common subtype of indolent non-Hodgkin lymphoma. Objective: To clarify the relationship between HCV and FL, we compared the prevalence of clinicopathologic characteristics between HCV-infected and HCV-non-infected FL patients. Design: A comparative retrospective study included 103 FL patients who presented at our institution during 2008-2018. Setting: It was carried out in the Hematology unit at Oncology Center, Mansoura University (OCMU). Patients: 103 patients with FL who were F/M (47.6/52.4%) with mean age 55.36 ± 11.82 years. The prevalence of HCV infection among FL patients was found to be 49.5%. Interventions: They were treated by rituximab ± anthracycline or alkylator-based regimens. Radiotherapy was the treatment of choice in selected low stage I/II. Main Outcome Measures: The impact of HCV infection on clinicopathological features of FL and its impact on clinical outcome. Results: In this study, HCV-positive FL patients commonly had B symptoms (P = 0.023), stage IV (P = 0.016), high FLIPI score (P =0.042) and absent BCL2 expression (P = 0.041). While no differences were detected regarding gender (P =0.28), grade (P = 0.78) and overall response rate (P = 0.2). PFS was significantly improved with low FLIPI score (P = 0.028), meanwhile, no differences were detected regarding HCV-status (P = 0.27) and grade (P = 0.17). Median OS was not reached. It was significantly improved in Grade 1, 2 (P Conclusion: The prevalence of HCV infection among our studied FL patients is ∼49.5%. HCV infection was significantly associated with more aggressive clinicopatholigical features and shortened OS. Thus, early detection and eradication of HCV infection in FL may improve the outcome.

Rectal gastrointestinal stromal tumours (GISTs) are uncommon tumours and usually present with large sizes. We present two cases of rectal GIST. Imatinib was used in the setting of neoadjuvant and adjuvant therapy. Both tumours were resected transanally by the transanal endoscopic operation (TEO) platform. Oncosurgeons are recommended to implement sphincter-sparing surgeries for these cases.

Background Hepatocellular carcinoma is the most common primary liver cancer that usually develops in a background of cirrhosis. It is usually diagnosed at advanced stages and abdominal pain may be the first presentation where it represents a significant cause of morbidity. Celiac plexus neurolysis (CPN) demonstrated good results in the relief of pain as a result of upper abdominal malignancy. Dexmedetomidine is an α2 adrenoreceptor highly selective agonist approved for procedural sedation use. Patients and methods Fifty patients who were divided into two groups with hepatocellular carcinoma-associated abdominal pain in need of opioid analgesics underwent endoscopic ultrasound-guided CPN using bupivacaine 0.5% alone with alcohol for the first group and bupivacaine 0.5% plus dexmedetomidine in the second one. Patients give their abdominal pain a score according to the numeric rating scale-11 before, 2, 4, 6, 8, 12, 16, and 24 week after the procedure. Results The study have included 50 patients who were divided in two groups: 32 men and 18 women with a mean age of 60.12±5.07 years for group 1 and 58.32±5.03 years for group 2. There were no significant difference between the two groups as regards medical, laboratory, or tumor characteristics. The median pain score decreases from 8.32±0.75 before the procedure to 3.75±3.72 24 week after the procedure in group 1 and from 8.08±0.86 before to 1.67±2.3 24 week after the procedure in group 2. However, there was no significant difference between the two groups in the median pain score during the first 4 weeks of follow-up. There was no statistically significant difference between the two groups as regards the median survival time. Conclusion The addition of dexmedetomidine to bupivacaine 0.5% in endoscopic ultrasound-CPN demonstrated beneficial effects as regards the degree and duration of pain relief with negligible effect on patient survival.