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Ahmed Aly Khalil, Mohamed Elshawy, Mohab Elbarbary, Yasser Elghamrini Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, EgyptCorrespondence: Ahmed Aly KhalilDepartment of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, EgyptEmail drahmedaly83@gmail.comBackground: Pilonidal sinus (PNS) is a common disorder that mainly affects young adults. It can be asymptomatic or presented by discomfort, inflammation, abscess or sinus formation. Despite current advances in surgical techniques, the best option to treat PNS is not yet well defined. Many studies reported techniques that involved excision of the sinus and closure of the deep and superficial layers but leaving the skin open.Aim: We aim to compare between the excision and primary midline closure with suction drain versus the partial closure technique as treatment options for PNS in terms of recovery, wound complications and recurrence rate.Patients and Methods: A prospective comparative study at Ain Shams University Hospitals that included 80 patients with PNS was conducted from January 2018 to June 2019. They were divided randomly into group A; 40 patients that had the midline closed method with suction drain and group B; 40 patients that underwent the partial closure technique. Both groups were followed up for 1 year, detecting healing time, wound complications, return to usual activities and recurrence rate.Results: We detected significant differences between both groups as regards to pain and discomfort postoperatively, favoring the partial closure group. Mean time to wound healing was significantly shorter among group A (14.43 ± 3.13) though mean time of return to usual activities was faster among the partial closure group (14.45 ± 1.15). There were no statistically significant differences between both groups as regards to wound infection, dehiscence or hematoma formation. Wound seroma was more among group A.Conclusion: The partial midline closure technique showed comparable results to the closed method with suction drain in management of PNS disease. Indeed, it shows less postoperative complications and a faster return to usual daily activity. Yet, more studies are required to demonstrate its reproducibility.Keywords: pilonidal sinus, primary midline closure, partial closure, wound complications

Aim Technical difficulties are usually reported in low rectal cancer (LRC) surgery. Moreover inadvertent surgical errors could happen mostly due to lack of experience of the assisting surgeons. Unfortunately, these errors may end up with raising a permanent stoma. In this study we are reporting seven inadvertent surgical mishaps during surgeries for LRC which resulted in failure of the planned circular end to end anastomosis and how we approached them by different salvage techniques. Patients and methods All surgical mistakes were salvaged by two of our senior consultants with intraoperative decision to shift to another approach to attain intestinal continuity. Two patients had direct handswen coloanal anastomosis, three received colon pull through and two with redo stapled circular end to end anastomosis after shifting to the anterior perineal plane. Postoperative assessment of the functional state using wexner score was done for all cases. Results All surgical mistakes had been overcomed after shifting to the transanal and/or perineal approach and we were able to regain intestinal continuity in all cases Circumferential and distal margins were free in all specimens. Two patients showed optimal continence with wexner score 3,5 respectively, Two had suboptimal continence Wexner 6,7. Female patient with iatrogenic rectovaginal fistula suffered from poor quality of life and asked for permanent stoma. Conclusion All trainees and junior fellows in should receive a clearly defined training program and focused education with different staplers; additionally they should work under supervision of the senior consultants who should be sufficiently experienced with different salvage approaches., Highlights • Low rectal cancer surgery is demanding even in the hands of experienced colorectal surgeons. • Inadvertent surgical errors could happen due to lack of experience of the assisting surgeons. • Salvage procedures may be the key to restore intestinal continuity. • All trainees and junior fellows in colorectal units should receive a clearly defined training programs.

Background Fecal incontinence is a frequent and debilitating condition that may result from a multitude of different causes. It is defined as the uncontrolled passage of faeces or gas over at least 1 month’s duration, in an individual of at least 4 years of age, who had previously achieved control. Aim of Work to evaluate the outcome of overlap anal sphincter repair as regard the anal continence and postoperative complications. Patients and Methods this is a prospective clinical trial was conducted on thirty (30) patients presented to Ain-Shams University hospitals with anal sphincter injury that were operated upon by a modified overlap repair done by the same surgical team. Endoanal ultrasonography was done and Wexner continence score was estimated for all cases preoperatively and postoperatively. All patients sharing in the study were fully informed about the procedure they had with a written informed consent. Results In this study the mean preoperative Wexner score was 12.9 and the mean postoperative Wexner was 4.8; this reduction was found to be significant (p value=0.001). Also endoanal ultrasound showed that tear size significantly reduced among the studied cases(p value=0.001). Conclusion from this study that overlapping sphincter repair is an effective method in the treatment of faecal incontinence in patients with repairable sphincter defects. However, long term follow up is required to confirm its efficacy.

Background: Venous thromboembolism (VTE) is a common postoperative complication after bariatric surgery with high mortality. Our study aimed to spotlight on the importance of anticoagulants after sleeve gastrectomy and its effect on lower limb deep venous thrombosis (DVT) incidence in obese patients with low BMI. Patients and methods: A prospective observational study was performed, including 200 patients with BMI between 35 and 45 kg/m2 undergoing laparoscopic sleeve gastrectomy (LSG) in the period between February 2017 and September 2018. Half of the patients received anti-thromboembolic dosage scheme of 0.5mg/kg/day with the induction of anaesthesia and for one week postoperatively (Group A) while the other half had no anticoagulation therapy (Group B). Results:Patients were followed with lower limb venous duplex at 2 weeks, 3 and 6 months interval from the operation or on appearance of symptoms of DVT. No patients had DVT in both groups by venous duplex. Conclusion: The incidence of lower limb DVT after LSG in patients with low BMI is not affected only by anticoagulants. We need further investigations including coagulation profile and congenital anticoagulation abnormalities to give an accurate idea about the influence of LSG on the incidence of DVT.

Bachground the principal advantages of this approach are a more precise diagnosis of appendicitis, reduction in post-operative pain, fewer superficial-surgical-site infection, earlier return to normal activity and reduction of the duration of hospital stay. Purpose to assess the preoperative patient and surgery risk factors that increase the likelihood of conversion of a laparoscopic appendectomy to an open Appendectomy in Egyptian patients. Patients and Methods this study was conducted in El Demerdash Hospital; Ain shams University, from December 2017 to June 2018. The study was conducted on 30 patients with suspected appendicitis. Results there were 30 patients identified who underwent an initial laparoscopic approach for acute appendicitis. The age range was from 18 to 52 years. The Female to Male ratio was 19:11. Of the 30 initial LA, 9 cases were converted to OA (30%). Conclusion surgeon can initiate open appendectomy or aim to have a low threshold of conversion if any of the above mention risk factors present in combination.

Background Exploratory laparotomy remains one of the common operations across the surgical disciplines. As such, the systematic and safe closure of such a laparotomy wound is the key to reduce the postoperative morbidity like wound pain, wound infection and incisional hernia. Objective To compare mass closure & Hughes repair in emergency laparotomy as regard intraoperative technique, operation time, incidence of complication as wound infection, dehiscence, burst abdomen and incisional hernia. Patients and Methods This is a prospective comparative study between two types of closure, mass closure and hughes repair in emergency laparotomies. This study was conducted at Ain-Shams University Emergency Hospitals. Patients who underwent emergency laprotomy from September 2017 to March 2018 and the patients were followed up postoperatively for six months. All patients who underwent emergency laparotomy at Ain-Shams University Emergency Hospitals from September 2017 to March 2018 were chosen according to inclusion and exclusion criteria. Results In this study we used the same suture and materials” Polydioxanone PDS loop 1”. The comparative study included several items to discuss starting from the time of the technique in our study it ranged from 12 -19 minutes in the conventional method “Mass closure” and it ranged from 24-31 minutes in the huge repair group. It was observed that the length of the laprotomy incision determine the time of the technique. The overall operative time of mass closure group was shorter than the hughe repair technique Conclusion It was observed that there were major factors that affected the results such as the reason for the laparotomy and the general condition of the patient especially the chest condition, diabetes mellitus, serum albumin, anemia and the body mass index.

Background Hernia is a common problem of the modern world with an incidence ranging from 5%-7%. Of all groin hernias, around 75% are inguinal hernias. Recently with advancement in laparoscopy, endoscopic repairs seem to offer better quality of life, decreasing hospital stay and early return to work. Aim of the Work To compare between self fixating mesh and non self fixating mesh in laproscopic inguinal hernia repair transabdominal preperitoneal (TAPP) approach as regards intraoperative time, complications, postoperative pain, return to normal activity and incidence of recurrence. Patients and Methods This study was conducted on 30 adult patients presenting with inguinal hernias. They were divided into 2 equal groups of 15 patients each. The first group (A): includes fifteen patients and was operated upon by a Laparoscopic transabdominal pre-peritoneal inguinal hernioplasty technique using self -gripping (SGM group) (Parietex ProGrip] Laparoscopic (PPL) meshes), while the second group (B): includes fifteen patients and were operated upon by a Laparoscopic transabdominal pre-peritoneal inguinal hernioplasty technique with non-self fixating mesh. Results The postoperative pain assessment at 24 hours and 4 weeks shows that the mean VAS score for GROUP A was (3.70 ± 1.72) and for GROUP B (3.90 ± 1.25) while after 1 month duration follow up, the mean VAS score was (1.25 ± 0.79) for Group A and (1.20 ± 0.77) for Group B with no difference between the two groups confirming the atraumatic nature of the self gripping mesh. Conclusion After this comparative study, both mesh fixation with absorpable tacks and fixation using SGM approaches are similarly effective in terms of operative time, the incidence of recurrence, complications and chronic pain coinciding with all the available literature.

The newly emerging, highly pathogenic avian influenza (HPAI) H5N8 virus of clade 2.3.4.4 was recently detected in wild birds and domestic poultry in Egypt in the 2016/2017 winter season. Vaccination based on commercial H5 vaccines is used as an essential control strategy in Egyptian poultry. Here, we studied the efficacy of the eight most common commercial H5 poultry vaccines in the Egyptian market and compared them with an experimental vaccine based on the Egyptian LPAI H5N8 virus that was prepared by using reverse genetics. The experimental vaccine and Re-5 commercial vaccine were able to completely protect chickens and significantly reduce virus shedding. Our results indicate that most of the commercial poultry H5 vaccines used in the present study were ineffective because the seed viruses in these vaccines are genetically distinct from the H5N8 viruses currently circulating in Egypt. Although some of the commercial vaccines protected chickens from mortality, they failed to prevent chickens from shedding the virus. Accordingly, we recommend updating and reinforcing the H5N8 prevention and control strategies in Egypt. The vaccination strategy should be reconsidered based on currently circulating viruses.

Background: Neuro-modulation of the pelvic nerves is an effective and promising modality for treating fecal incontinence. Direct sacral nerve stimulation is the most popular for neuro-modulation although it is technically demanding. Percutaneous and transcutaneous posterior tibial nerve stimulations are relatively newer approaches for neuro-modulation and they carry the advantage of being cheaper and less invasive. There is not much published data about the transcutaneous approach and in this study, we are describing our experience with this technique. Objective: This study was conducted to describe and determine the efficacy of percutaneous posterior tibial nerve stimulation in the treatment of fecal incontinence. Design: A prospective descriptive study. Setting: The colorectal clinic in the hospital was prepared with the required equipment. The authors funded all procedures performed and the patients paid no extra charges. Patients and Methods: Our study included 15 patients with fecal incontinence visiting the colorectal clinic in Ain Shams University Hospital. All patients received 12 sessions of electric stimulation, 3 sessions per week for 40 minutes each. Main Outcome Measures: Sample Size Wexner score and the short term effect of the treatment. Sample Size: 15 patients. Results: The study included 11 females and 4 males, 2 patients were excluded from the results. The results showed that there was improvement in mean Wexner score for these patients from 13 before the treatment to 8 after finishing the treatment course. Reassessment after 6 months of treatment revealed no deterioration in their continence. Conclusion: We found that transcutaneous posterior tibial nerve stimulation is an effective, cheap, and tolerable method for treating fecal incontinence. However, long-term follow up is required on larger group of patients to adopt this technique. Limitations: Small sample size, short course follow up.Conflict of Interest: None.

Ileal pouch anal anastomosis is a commonly performed procedure. The operation can be completed in one stage, two stages, or three stages depending on the general condition of the patient and the local condition of the bowel. The J pouch is the most commonly performed pouch design. After construction, the pouch mesentery can be short, necessitating ligation and division of the superior mesenteric pedicel to allow the pouch reach the anal canal at ease. In this case, the ileocolic pedicle should be intact to give alternative blood supply to the newly constructed pouch. The ileocolic pedicle can be inadvertently injured during dissection to take down the ileostomy in the second stage of a three-stage operation. This can risk the pouch integrity in case the superior mesenteric pedicle needs to be divided. We are describing a method to avoid such inadvertent ileocolic vessel injury. After adopting this method, we did not have a single incident of ileocolic vessel injury in the second stage of a three-stage ileal pouch anal anastomosis.