Background & Objective: Hypofractionation has been used in curative setting in breast conservativ... more Background & Objective: Hypofractionation has been used in curative setting in breast conservative surgery, but still no adequate information about its application in the adjuvant setting after mastectomy in breast cancer patients. The aim of this trial was to assess the efficacy and toxicity of hypofractionation radiotherapy (40 Gy in 15 fractions) in post mastectomy breast cancer patients and to compare these results with those of post mastectomy patients treated retrospectively by conventional radiotherapy (50 Gy in 25 fractions) as regard overall survival (OS), disease free survival (DFS), locoregional disease free survival (LDFS), and toxicities. Patients & Methods: One hundred post mastectomy breast cancer patients were included into this study, they were divided into 2 groups, the 1st included 50 patients treated prospectively with hypofractionated radiotherapy regimen (40 Gy in 15 fractions), and the 2nd (control group) included 50 patients treated retrospectively with conventionally fractionated radiotherapy regimen (50 Gy in 25 fractions). Results: The 2 year overall survival were 96% & 94% respectively (p = 0.7), while the disease free survival were 91% & 89.8%, respectively (p = 0.9), and the LDFS were 95.8% & 93.3%, respectively (p = 0.9), G1 acute dermatitis was observed in 22 (44%) & 25 (50%) patients in group I & II respectively, G2 in 8 (16%) & 10 (20%) patients respectively, no G4 skin toxicity was detected. Radiation pneumonitis was observed in 2 patients (4%) only in group II. Conclusion: post-mastectomy hypofractionated radiation therapy achieved comparable survival and toxicity to the conventionally fractionated radiotherapy with the advantage of reducing overall treatment time, treatment burden & cost.
Introduction: Nowadays the more accepted surgical option for treating early breast cancer is brea... more Introduction: Nowadays the more accepted surgical option for treating early breast cancer is breast conserving surgery. The main challenge in this type of surgery is to get free safety margins without need of second surgical operation, so many breast surgeons have started to depend on intraoperative frozen sections to ensure free safety margins. Aim of work: To assess our policy that we prefer to depend on intraoperative frozen section analysis to get free safety margin in breast conserving surgery from the 1st surgery, and its oncologic outcome. Patients and Methods: This is a retrospective study conducted in Oncology Center—Mansoura University (OCMU), where the data of 219 patients with breast cancer, who were managed by breast conserving surgery with intraoperative frozen section analysis of the safety margins, was analyzed. Results: The intraoperative frozen section analysis of safety margin was negative from the start in 183 (83.6%) patients, while it was positive in 36 patient...
Background: The study aims to assess the functional outcome of anal sphincter sparing procedures ... more Background: The study aims to assess the functional outcome of anal sphincter sparing procedures (SSP) with TME for anorectal adenocarcinoma.Methods: In a multicentric, prospective, single-group study in the period between December 2012 and November 2017, 93 patients presented with anorectal adenocarcinoma were included in the study. Sixty-nine patients underwent SSP with TME. SSP included the combined approach of transabdominal TME with intersphincteric resection (ISR) or transanal transabdominal TME (TATA). Using the Per Anal Examination Scoring System (PASS), postoperative anal function was assessed after one year.Results: Bowel motility time was 50 (±19) hours. The time needed for narcotic analgesia was 54 (±18.8) hours. Mean hospital stay was 15.4 (±10.25) days. Incidence of evident fecal incontinence after ISR is 10.6% (7/67 cases). The Per Anal Examination Scoring System (PASS) findings of 69 cases are as follows: extremely hypotonic 8.6% (6 cases), slightly hypotonic 26.1% (...
Performing pedicled TRAM in obese women carries risk of flap loss or native breast envelop necros... more Performing pedicled TRAM in obese women carries risk of flap loss or native breast envelop necrosis. Our technique depends on performing total flap delay at the same setting with mastectomy with flap suture in situ to be followed 1 week later by flap transfer. This study included 24 operable women who were candidates for skin sparing or modified radical mastectomy. In one case, delay was only done and followed by mastectomy and flap transfer. In later experience, delay plus mastectomy was done first and followed later by flap transfer. Operative data and postoperative complications were recorded. The mean BMI was 37 ± 2.75. The mean total operative time was 200 ± 20.37. The mean total hospital stay was 9.1 ± 3.35 days. The mean total volume of blood loss was 380 ± 82.33 ml. Breast envelop necrosis was encountered in four cases; three of them were replaced by the TRAM skin. There was no total flap loss while partial loss was recorded in five cases. Fat necrosis occurred in eight cases. Most of mastectomy bed and abdominal complications were in average. Most of cases showed satisfactory esthetic outcome. Our new concept of BInterval TRAM^enables safe immediate breast reconstruction with pedicled TRAM in obese women and ensures presence of a skin pack up for the native breast envelop skin. We recommend this technique in every obese female who undergoes skin sparing mastectomy with immediate pedicled TRAM flap reconstruction.
We aimed at evaluation of the clinicoepidemiologic data of patients with gastric carcinoma in the... more We aimed at evaluation of the clinicoepidemiologic data of patients with gastric carcinoma in the Egyptian Delta as regards the etiologic factors, behavior, presenting symptoms, and tumor location, grade, and stage with highlighting of the treatment modalities, survival, and prognostic factors. Three hundred cases with gastric carcinoma were enrolled, diagnosed, and treated in a tertiary oncology center in the Egyptian Delta. Data were collected as regards the etiology, presenting symptoms, family history, comorbid conditions, treatment modalities, responses, recurrences, and survival outcomes. Univariate and multivariate analyses were done to correlate the different clinicopathologic factors with the overall and disease-free survivals. Male to female ratio was 2:1. The median age was 43 years. The main tumor location was in the gastric body. Pain was the commonest presenting symptom (36%). Most of the cases were stage IV (42.0%). Only 49% of cases were operable. On multivariate analysis, age more than 60 years, performance status 3-4, high grade, diffuse type, T4 lesions, N2 and N3, and the presence of metastasis were independently associated with worse OS. We report a clinic-epidemiologic study of gastric carcinoma in the Egyptian delta; the age at presentation was a decade earlier than that recorded in the USA and Europe; most of the cases were sporadic, located mostly at the body. Most of the cases were presented at stage IV with poor response to neoadjuvant therapy with a poorer overall survival than that recorded in the USA and Europe.
International Journal of Radiation Oncology*Biology*Physics, 2014
an eyeball phantom that uses a programmable x-y motion stage with a connected joystick to drive t... more an eyeball phantom that uses a programmable x-y motion stage with a connected joystick to drive the simulated eyeball's rotational movement. Results: Both tumor (size and location inside the eyeball) and eyeball (size) were fabricated in the size similar to human's. Eyeball's movement can be programmed in various speeds and patterns. Experimental data from phantom validation under the CT simulator and from the 2D/ 3D transformation based on the video camera tracking were obtained. For eight testing positions (center of the simulated tumor) in the validation experiment, we compared the ground true coordinate from the CT space and predicted coordinate from our derived transformation. The maximum root-sum-squared error (RSSE) of three coordinates (X, Y, Z) is less than 0.70 mm and the mean-squared error is 0.44 mm among eight test positions. Conclusions: This video camera tracking technique and the 2D/3D transformation are feasible for robotic radiosurgery on ocular tumor. Error analysis indicates that the accuracy is clinically acceptable.
International Journal of Gynecological Cancer, 2005
Objective: To compare laparoscopic surgery with conventional abdominal surgery in patients with e... more Objective: To compare laparoscopic surgery with conventional abdominal surgery in patients with early stage endometrial cancer. Methods: A retrospective review of 63 patients with early stage endometrial cancer managed between March 2003 and May 2005. Two groups were defined whether they had been treated by laparoscopy (case group: n=26) or by laparotomy (control group: n=37). We compared age, body mass index (BMI), hemoglobin change, operation time, number of pelvic lymph nodes, hospital stay, case with adjuvant treatment and recurrence between two groups. Results: There was no statistical difference in characteristics (age, BMI, nulliparity, previous abdominal surgery, FIGO stage, histologic grade). between case and control group. In addition, there was no statistical difference in operation data and outcomes between two groups. Hemoglobin changes were 1.1 g/dL (case group) vs 1.7 g/dL (control group) (p=0.072). Operation time was 131 min vs. 115 min. The numbers of lymph nodes obtained were 8.7 vs 7.7 (right) 9.2 vs. 7.6 (left). Hospital stays were 8.4 vs. 9.2 days. Adjuvant treatment cases were 7 vs. 15. Recurrent case was one in each group. Two patients initially evaluated by laparoscopy were converted to laparotomy due to bleeding and adhesion. Conclusion: Laparoscopic surgery for treatment of early endometrial cancer is a safe and effective alternative to laparotomy. However, long-term survival and risk of recurrence have yet to be determined.
Background: The latissimus dorsi (LD) muscle flap plays an essential role in breast reconstructio... more Background: The latissimus dorsi (LD) muscle flap plays an essential role in breast reconstruction after partial mastectomy for cancer because of its stability and versatility. We evaluated both oncologic and aesthetic outcomes in addition to the related complications of this flap as an adjunct to breast conserving surgery in the management of breast cancer patients. Methods: All patients underwent a one-stage procedure with immediate reconstruction through two-steps operation; wider local excision utilizing oncoplastic principles and mini flap harvest & volume replacement. Results: The study included 34 cases with early breast cancer; 30 patients had partial breast resection and defect refilling by LD mini-flap, three patients underwent mastectomy and one patient underwent extended LDF. The mean defect volume was (212.63 cm³ ± 59.57) cm³, while the mean flap volume was (218.27 cm³ ± 53.64 cm³). Patient self-evaluation of the cosmetic outcome was excellent in 20%, good in 60% and satisfactory in 20% of patients. Panel evaluation according to Harvard scale showed excellent in 36.7%, good in 36.7%, fair in 26.7% of patients. The median hospital stay was 4 days. The postoperative complications included wound gap in 4 patients (13.3%), postoperative donor site seroma in 16 patients (53.3%). No flap loss or necrosis, no affection on arm or shoulder mobility occurred. Lastly, no tumor recurrence till now. Conclusion: Latissimus dorsi mini-flap can achieve adequate cosmetic and oncologic outcomes with a low incidence of complications in patients with early stage (I/II) breast cancer and small to medium sized breasts.
Objectives: The use of omental flap for breast reconstruction was reported by the Romanian surgeo... more Objectives: The use of omental flap for breast reconstruction was reported by the Romanian surgeon Kiricuta in 1963, since that time some surgeons tried to use the omentum either pedicled or free for breast reconstruction. It can be used after partial or total mastectomy. Aims: The aim of this chapter is to address indications, limitations, contraindications, and technique of omental flap for breast reconstruction. Technique: This flap could be retrieved by either a small midline laparotomy or preferably by laparoscopic harvesting. Details of retrieval, tips and tricks are highlighted in this chapter. Conclusions: Omental flap is a strong working horse in breast reconstruction after partial or skin sparing mastectomy (SSM). It can be free or pedicled. It could be retrieved by minilaparotomy or preferably by laparoscopic harvesting omental flap (LHOF). It is a simple, safe, and reliable flap that mimics the natural contour of the breast. In about 30% with volume insufficiency it can be used with an implant as a cover with low complication rate and good esthetic outcome.
Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in ach... more Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in achieving the best oncologic and functional results. Reconstruction of the digestive tract to restore postpharyngectomy continuity is challenging. Free jejunum transfer remains the most reliable option. Micro vascular techniques minimize partial flap necrosis and the subsequent salivary fistula and are superior to pedicled flaps. Improving the results of free jejunum pharyngeal substitute is thus of utmost importance to the success of treatment of patients with hypo pharyngeal carcinoma. Methods: Refinement plan: Considerations for organ preservation determine the choice of therapy in the majority of cases. Most patients present with stage III or resectable stage IV tumors. Combined surgery and chemo-irradiation is essential for these patients. A few of our patients present as early cancers (stage I, II). Surgical ablative phase: the majority of patients need formal total laryngectomy, phar...
Omental flap was introduced for breast reconstruction after mastectomy either alone or as an adju... more Omental flap was introduced for breast reconstruction after mastectomy either alone or as an adjunct to prosthetic reconstruction. Laparoscopically harvested omental flap was used successfully for this issue. Most of reports had described its use after partial mastectomy, skin or nipple areola sparing mastectomies. In this case, we used the thoracodorsal artery perforator (Tdap) flap as a cover for the omental flap in a patient who underwent modified radical mastectomy. Modified radical mastectomy was done in the usual fashion. The descending branch of the thoracodorsal vessel was traced till its main perforator in an antegrade fashion. Then, the supplied skin island flap was created and rotated to cover the laparoscopically harvested omental flap that was delivered after its mobilization through a small epigastric wound from underneath the inner aspect of the lower mastectomy flap. The overall operative time was around 150 min. No blood transfusion was required. Pain score was around 6–7 in the early postoperative hours. No major complications were encountered, and the patient was discharged at the third postoperative day. The overall esthetic score was expressed as “good.” To our knowledge, this is the first time to report usage of laparoscopically harvested omental flap after modified radical mastectomy with skin coverage by the thoracodorsal artery perforator (Tdap) flap. One criticism that may arise is the dual flap reconstruction; however, this method still as an alternative to the myocutaneous flaps with a reasonable operative time and minimal donor site and overall morbidities with good esthetic outcome. Modified radical mastectomy can be safely and efficiently reconstructed using a laparoscopically harvested omental flap with a cutaneous coverage using the thoracodorsal artery perforator (Tdap) flap.
Supraclavicular nodal metastases of breast cancer are rare and occur in about 8% of newly diagnos... more Supraclavicular nodal metastases of breast cancer are rare and occur in about 8% of newly diagnosed cases. It is rarely discussed in the literature that breast cancer was metastasizing to higher levels of the cervical nodes. We report a case of metastatic breast cancer to the deep cervical lymph nodes that caused stridor due to compression of the recurrent laryngeal nerve which was diagnosed by indirect laryngoscopy. After full investigations, urgent chemotherapy was started and it showed a dramatic response with disappearance of the lymph node after two cycles with resolution of the stridor. This report also highlights the association of other metastatic sites with this higher level of neck nodal metastases of breast cancer.
This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total e... more This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total endoscopic submandibular sialadenectomy through a chest wall approach without the creation of any neck incisions. Four patients with benign submandibular gland lesions underwent a total endoscopic submandibular sialadenectomy through a chest wall approach using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments). The operative time ranged from 140 to 170 minutes. Conversion to the open technique was only necessary in one case with good visualization of the facial vein and artery, marginal mandibular and lingual nerve. No significant perioperative complications were encountered. All patients were discharged on the third postoperative day, and they were satisfied with the cosmetic outcome. Total endoscopic submandibular sialadenectomy through a chest wall approach is technically feasible and safe with satisfactory cosmetic results. It may be a valid altern...
The surgical treatments of hepatocellular carcinoma (HCC) in a cirrhotic liver include both hepat... more The surgical treatments of hepatocellular carcinoma (HCC) in a cirrhotic liver include both hepatic resection and liver transplant. While the liver transplant is considered as a golden therapy, it has some obstacles including shortage of organs especially living donors, economic circumstances, and the progression of a tumor while waiting for the transplant so the second choice which is resection should have a role. In this study, 84 patients with HCC (who were legible for transplant according to Milan and extended selection criteria) were enrolled for hepatic resection. The outcome including complication and the oncologic outcome was evaluated. We followed our patients for 15 months as a median follow-up (range from 3 to 50 months); we noticed 10 tumor relapse (11.7%) and seven lost (8.3%). We also noticed no recurrence. Patients' overall survival showed a median of 15 and 50 months, respectively. We can conclude that there is reasonability for HR as an effective optional treatment for patients with HCC who are legible for transplant particularly for patients with a Child-A scoring.
Tongue resection is a surgical challenge because of its adverse effects on language articulation,... more Tongue resection is a surgical challenge because of its adverse effects on language articulation, swallowing, respiration, the eventual quality of life, and poor prognosis of advanced disease. To date, the currently accepted standard treatment has been based on excision of the primary lesion with a 1.5-2-cm circumferential macroscopic margin. Compartmental tongue surgery (CTS) is a surgical technique that removes an anatomo-functional compartment containing the primary tumor. This is a prospective study that was carried out from June 2012 to January 2015 for patients with carcinoma affecting oral tongue. We enrolled all cases with ≥T2 tongue cancer with or without infiltration of floor of the mouth. Patients underwent compartmental tongue resection with reconstruction using island submental flap. Pharyngeal tear occurred in two cases that were repaired by simple suture. Bleeding occurred in two cases with control of the affected vessels. Loco-regional recurrence was detected only in two cases that underwent CTS, while 18 patients who underwent traditional tongue resection had local recurrence. CTS via pull through technique with submental island flap reconstruction for large tongue cancer has been evolved to improve oncologic resections, obtaining a better local control of disease and increased survival rate with concomitant successful functional and esthetic outcomes especially in elderly patients with serious comorbidities.
Objective: Nerve blockade is commonly used in oncosurgical procedures as an alternative to genera... more Objective: Nerve blockade is commonly used in oncosurgical procedures as an alternative to general anesthesia for older patients and those with significant medical problems. We report a single tertiary oncology center experience in performing various lip resections and reconstructive techniques using this technique. Patients and methods: sixty patients with lower lip tumors were enrolled into this study with exclusion of refusing, non-compliant and critically ill patients. A solution of 4 ml 2% Lidocaine and epinephrine was put in a 5 ml syringe. Half the solution (2 ml) was injected into each side with a 23 gauge needle and after 5 minutes the surgical resection was carried out after testing for anesthesia. Results: The mean age was 68 ± 6.2 years. The mean ASA score was 3 ± 0.75. There were 4 cases who expressed painful sensation and their operations were completed with fentanyl increments. Mean hospital stay was 1 ± 0.75 days. There were three cases of wound gaping who were treated with secondary closure in an outpatient basis. One patient expressed postoperative acute ischemic heart pain that was managed with anti-ischemic measurements. Conclusion: Bilateral mental nerve block is a safe and effective alternative to general anesthesia in lower lip tumors' resection especially in older patients and those with poor tolerance for general anesthesia provided that there is no need for cervical nodal dissection.
Background: Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a d... more Background: Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a diluting saline solution that makes flaps firm and tense, thus minimizing systemic drugs toxicity and making surgery possible with minimal bleeding. This technique is very useful in elder women and those with American Society of Anesthesiologists; score III and IV. The objective was to establish an alternative safe technique to general anesthesia in some selected mastectomy patients. Patients and methods: Twenty candidate women for total mastectomy and axillary dissection were enrolled and consented to participate. After preparation, an anatomically directed infiltration was made under sedation, using a cocktail of lidocaine, bupivacaine, and epinephrine, followed after 20 minutes by the surgical incision and completion of mastectomy. All intraoperative and postoperative outcomes were recorded. Results: Although 7 cases required added analgesic medications, no conversion for general anesthesia was recorded. Mean operative time was 81±15.8 minutes. Mean blood loss was 95.8±47.5 mL. There was no recorded intraoperative hemodynamic instability. Postoperative visual analog score was not exceeding 4 till the end of the first 24 hours. Opioids were not required in any case, and the mean dosage of Ketorolac used was 30±8.75 mg. Drains output and the incidence of postoperative complications were acceptable. Conclusion: We can consider tumescent mastectomy in well-selected patients a safe alternative for performing mastectomy when general anesthesia is hazardous, with minimal blood loss and long lasting postoperative analgesia without an additive effect on the operative time, hospital stay, and intraoperative and postoperative complications.
Background & Objective: Hypofractionation has been used in curative setting in breast conservativ... more Background & Objective: Hypofractionation has been used in curative setting in breast conservative surgery, but still no adequate information about its application in the adjuvant setting after mastectomy in breast cancer patients. The aim of this trial was to assess the efficacy and toxicity of hypofractionation radiotherapy (40 Gy in 15 fractions) in post mastectomy breast cancer patients and to compare these results with those of post mastectomy patients treated retrospectively by conventional radiotherapy (50 Gy in 25 fractions) as regard overall survival (OS), disease free survival (DFS), locoregional disease free survival (LDFS), and toxicities. Patients & Methods: One hundred post mastectomy breast cancer patients were included into this study, they were divided into 2 groups, the 1st included 50 patients treated prospectively with hypofractionated radiotherapy regimen (40 Gy in 15 fractions), and the 2nd (control group) included 50 patients treated retrospectively with conventionally fractionated radiotherapy regimen (50 Gy in 25 fractions). Results: The 2 year overall survival were 96% & 94% respectively (p = 0.7), while the disease free survival were 91% & 89.8%, respectively (p = 0.9), and the LDFS were 95.8% & 93.3%, respectively (p = 0.9), G1 acute dermatitis was observed in 22 (44%) & 25 (50%) patients in group I & II respectively, G2 in 8 (16%) & 10 (20%) patients respectively, no G4 skin toxicity was detected. Radiation pneumonitis was observed in 2 patients (4%) only in group II. Conclusion: post-mastectomy hypofractionated radiation therapy achieved comparable survival and toxicity to the conventionally fractionated radiotherapy with the advantage of reducing overall treatment time, treatment burden & cost.
Introduction: Nowadays the more accepted surgical option for treating early breast cancer is brea... more Introduction: Nowadays the more accepted surgical option for treating early breast cancer is breast conserving surgery. The main challenge in this type of surgery is to get free safety margins without need of second surgical operation, so many breast surgeons have started to depend on intraoperative frozen sections to ensure free safety margins. Aim of work: To assess our policy that we prefer to depend on intraoperative frozen section analysis to get free safety margin in breast conserving surgery from the 1st surgery, and its oncologic outcome. Patients and Methods: This is a retrospective study conducted in Oncology Center—Mansoura University (OCMU), where the data of 219 patients with breast cancer, who were managed by breast conserving surgery with intraoperative frozen section analysis of the safety margins, was analyzed. Results: The intraoperative frozen section analysis of safety margin was negative from the start in 183 (83.6%) patients, while it was positive in 36 patient...
Background: The study aims to assess the functional outcome of anal sphincter sparing procedures ... more Background: The study aims to assess the functional outcome of anal sphincter sparing procedures (SSP) with TME for anorectal adenocarcinoma.Methods: In a multicentric, prospective, single-group study in the period between December 2012 and November 2017, 93 patients presented with anorectal adenocarcinoma were included in the study. Sixty-nine patients underwent SSP with TME. SSP included the combined approach of transabdominal TME with intersphincteric resection (ISR) or transanal transabdominal TME (TATA). Using the Per Anal Examination Scoring System (PASS), postoperative anal function was assessed after one year.Results: Bowel motility time was 50 (±19) hours. The time needed for narcotic analgesia was 54 (±18.8) hours. Mean hospital stay was 15.4 (±10.25) days. Incidence of evident fecal incontinence after ISR is 10.6% (7/67 cases). The Per Anal Examination Scoring System (PASS) findings of 69 cases are as follows: extremely hypotonic 8.6% (6 cases), slightly hypotonic 26.1% (...
Performing pedicled TRAM in obese women carries risk of flap loss or native breast envelop necros... more Performing pedicled TRAM in obese women carries risk of flap loss or native breast envelop necrosis. Our technique depends on performing total flap delay at the same setting with mastectomy with flap suture in situ to be followed 1 week later by flap transfer. This study included 24 operable women who were candidates for skin sparing or modified radical mastectomy. In one case, delay was only done and followed by mastectomy and flap transfer. In later experience, delay plus mastectomy was done first and followed later by flap transfer. Operative data and postoperative complications were recorded. The mean BMI was 37 ± 2.75. The mean total operative time was 200 ± 20.37. The mean total hospital stay was 9.1 ± 3.35 days. The mean total volume of blood loss was 380 ± 82.33 ml. Breast envelop necrosis was encountered in four cases; three of them were replaced by the TRAM skin. There was no total flap loss while partial loss was recorded in five cases. Fat necrosis occurred in eight cases. Most of mastectomy bed and abdominal complications were in average. Most of cases showed satisfactory esthetic outcome. Our new concept of BInterval TRAM^enables safe immediate breast reconstruction with pedicled TRAM in obese women and ensures presence of a skin pack up for the native breast envelop skin. We recommend this technique in every obese female who undergoes skin sparing mastectomy with immediate pedicled TRAM flap reconstruction.
We aimed at evaluation of the clinicoepidemiologic data of patients with gastric carcinoma in the... more We aimed at evaluation of the clinicoepidemiologic data of patients with gastric carcinoma in the Egyptian Delta as regards the etiologic factors, behavior, presenting symptoms, and tumor location, grade, and stage with highlighting of the treatment modalities, survival, and prognostic factors. Three hundred cases with gastric carcinoma were enrolled, diagnosed, and treated in a tertiary oncology center in the Egyptian Delta. Data were collected as regards the etiology, presenting symptoms, family history, comorbid conditions, treatment modalities, responses, recurrences, and survival outcomes. Univariate and multivariate analyses were done to correlate the different clinicopathologic factors with the overall and disease-free survivals. Male to female ratio was 2:1. The median age was 43 years. The main tumor location was in the gastric body. Pain was the commonest presenting symptom (36%). Most of the cases were stage IV (42.0%). Only 49% of cases were operable. On multivariate analysis, age more than 60 years, performance status 3-4, high grade, diffuse type, T4 lesions, N2 and N3, and the presence of metastasis were independently associated with worse OS. We report a clinic-epidemiologic study of gastric carcinoma in the Egyptian delta; the age at presentation was a decade earlier than that recorded in the USA and Europe; most of the cases were sporadic, located mostly at the body. Most of the cases were presented at stage IV with poor response to neoadjuvant therapy with a poorer overall survival than that recorded in the USA and Europe.
International Journal of Radiation Oncology*Biology*Physics, 2014
an eyeball phantom that uses a programmable x-y motion stage with a connected joystick to drive t... more an eyeball phantom that uses a programmable x-y motion stage with a connected joystick to drive the simulated eyeball's rotational movement. Results: Both tumor (size and location inside the eyeball) and eyeball (size) were fabricated in the size similar to human's. Eyeball's movement can be programmed in various speeds and patterns. Experimental data from phantom validation under the CT simulator and from the 2D/ 3D transformation based on the video camera tracking were obtained. For eight testing positions (center of the simulated tumor) in the validation experiment, we compared the ground true coordinate from the CT space and predicted coordinate from our derived transformation. The maximum root-sum-squared error (RSSE) of three coordinates (X, Y, Z) is less than 0.70 mm and the mean-squared error is 0.44 mm among eight test positions. Conclusions: This video camera tracking technique and the 2D/3D transformation are feasible for robotic radiosurgery on ocular tumor. Error analysis indicates that the accuracy is clinically acceptable.
International Journal of Gynecological Cancer, 2005
Objective: To compare laparoscopic surgery with conventional abdominal surgery in patients with e... more Objective: To compare laparoscopic surgery with conventional abdominal surgery in patients with early stage endometrial cancer. Methods: A retrospective review of 63 patients with early stage endometrial cancer managed between March 2003 and May 2005. Two groups were defined whether they had been treated by laparoscopy (case group: n=26) or by laparotomy (control group: n=37). We compared age, body mass index (BMI), hemoglobin change, operation time, number of pelvic lymph nodes, hospital stay, case with adjuvant treatment and recurrence between two groups. Results: There was no statistical difference in characteristics (age, BMI, nulliparity, previous abdominal surgery, FIGO stage, histologic grade). between case and control group. In addition, there was no statistical difference in operation data and outcomes between two groups. Hemoglobin changes were 1.1 g/dL (case group) vs 1.7 g/dL (control group) (p=0.072). Operation time was 131 min vs. 115 min. The numbers of lymph nodes obtained were 8.7 vs 7.7 (right) 9.2 vs. 7.6 (left). Hospital stays were 8.4 vs. 9.2 days. Adjuvant treatment cases were 7 vs. 15. Recurrent case was one in each group. Two patients initially evaluated by laparoscopy were converted to laparotomy due to bleeding and adhesion. Conclusion: Laparoscopic surgery for treatment of early endometrial cancer is a safe and effective alternative to laparotomy. However, long-term survival and risk of recurrence have yet to be determined.
Background: The latissimus dorsi (LD) muscle flap plays an essential role in breast reconstructio... more Background: The latissimus dorsi (LD) muscle flap plays an essential role in breast reconstruction after partial mastectomy for cancer because of its stability and versatility. We evaluated both oncologic and aesthetic outcomes in addition to the related complications of this flap as an adjunct to breast conserving surgery in the management of breast cancer patients. Methods: All patients underwent a one-stage procedure with immediate reconstruction through two-steps operation; wider local excision utilizing oncoplastic principles and mini flap harvest & volume replacement. Results: The study included 34 cases with early breast cancer; 30 patients had partial breast resection and defect refilling by LD mini-flap, three patients underwent mastectomy and one patient underwent extended LDF. The mean defect volume was (212.63 cm³ ± 59.57) cm³, while the mean flap volume was (218.27 cm³ ± 53.64 cm³). Patient self-evaluation of the cosmetic outcome was excellent in 20%, good in 60% and satisfactory in 20% of patients. Panel evaluation according to Harvard scale showed excellent in 36.7%, good in 36.7%, fair in 26.7% of patients. The median hospital stay was 4 days. The postoperative complications included wound gap in 4 patients (13.3%), postoperative donor site seroma in 16 patients (53.3%). No flap loss or necrosis, no affection on arm or shoulder mobility occurred. Lastly, no tumor recurrence till now. Conclusion: Latissimus dorsi mini-flap can achieve adequate cosmetic and oncologic outcomes with a low incidence of complications in patients with early stage (I/II) breast cancer and small to medium sized breasts.
Objectives: The use of omental flap for breast reconstruction was reported by the Romanian surgeo... more Objectives: The use of omental flap for breast reconstruction was reported by the Romanian surgeon Kiricuta in 1963, since that time some surgeons tried to use the omentum either pedicled or free for breast reconstruction. It can be used after partial or total mastectomy. Aims: The aim of this chapter is to address indications, limitations, contraindications, and technique of omental flap for breast reconstruction. Technique: This flap could be retrieved by either a small midline laparotomy or preferably by laparoscopic harvesting. Details of retrieval, tips and tricks are highlighted in this chapter. Conclusions: Omental flap is a strong working horse in breast reconstruction after partial or skin sparing mastectomy (SSM). It can be free or pedicled. It could be retrieved by minilaparotomy or preferably by laparoscopic harvesting omental flap (LHOF). It is a simple, safe, and reliable flap that mimics the natural contour of the breast. In about 30% with volume insufficiency it can be used with an implant as a cover with low complication rate and good esthetic outcome.
Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in ach... more Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in achieving the best oncologic and functional results. Reconstruction of the digestive tract to restore postpharyngectomy continuity is challenging. Free jejunum transfer remains the most reliable option. Micro vascular techniques minimize partial flap necrosis and the subsequent salivary fistula and are superior to pedicled flaps. Improving the results of free jejunum pharyngeal substitute is thus of utmost importance to the success of treatment of patients with hypo pharyngeal carcinoma. Methods: Refinement plan: Considerations for organ preservation determine the choice of therapy in the majority of cases. Most patients present with stage III or resectable stage IV tumors. Combined surgery and chemo-irradiation is essential for these patients. A few of our patients present as early cancers (stage I, II). Surgical ablative phase: the majority of patients need formal total laryngectomy, phar...
Omental flap was introduced for breast reconstruction after mastectomy either alone or as an adju... more Omental flap was introduced for breast reconstruction after mastectomy either alone or as an adjunct to prosthetic reconstruction. Laparoscopically harvested omental flap was used successfully for this issue. Most of reports had described its use after partial mastectomy, skin or nipple areola sparing mastectomies. In this case, we used the thoracodorsal artery perforator (Tdap) flap as a cover for the omental flap in a patient who underwent modified radical mastectomy. Modified radical mastectomy was done in the usual fashion. The descending branch of the thoracodorsal vessel was traced till its main perforator in an antegrade fashion. Then, the supplied skin island flap was created and rotated to cover the laparoscopically harvested omental flap that was delivered after its mobilization through a small epigastric wound from underneath the inner aspect of the lower mastectomy flap. The overall operative time was around 150 min. No blood transfusion was required. Pain score was around 6–7 in the early postoperative hours. No major complications were encountered, and the patient was discharged at the third postoperative day. The overall esthetic score was expressed as “good.” To our knowledge, this is the first time to report usage of laparoscopically harvested omental flap after modified radical mastectomy with skin coverage by the thoracodorsal artery perforator (Tdap) flap. One criticism that may arise is the dual flap reconstruction; however, this method still as an alternative to the myocutaneous flaps with a reasonable operative time and minimal donor site and overall morbidities with good esthetic outcome. Modified radical mastectomy can be safely and efficiently reconstructed using a laparoscopically harvested omental flap with a cutaneous coverage using the thoracodorsal artery perforator (Tdap) flap.
Supraclavicular nodal metastases of breast cancer are rare and occur in about 8% of newly diagnos... more Supraclavicular nodal metastases of breast cancer are rare and occur in about 8% of newly diagnosed cases. It is rarely discussed in the literature that breast cancer was metastasizing to higher levels of the cervical nodes. We report a case of metastatic breast cancer to the deep cervical lymph nodes that caused stridor due to compression of the recurrent laryngeal nerve which was diagnosed by indirect laryngoscopy. After full investigations, urgent chemotherapy was started and it showed a dramatic response with disappearance of the lymph node after two cycles with resolution of the stridor. This report also highlights the association of other metastatic sites with this higher level of neck nodal metastases of breast cancer.
This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total e... more This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total endoscopic submandibular sialadenectomy through a chest wall approach without the creation of any neck incisions. Four patients with benign submandibular gland lesions underwent a total endoscopic submandibular sialadenectomy through a chest wall approach using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments). The operative time ranged from 140 to 170 minutes. Conversion to the open technique was only necessary in one case with good visualization of the facial vein and artery, marginal mandibular and lingual nerve. No significant perioperative complications were encountered. All patients were discharged on the third postoperative day, and they were satisfied with the cosmetic outcome. Total endoscopic submandibular sialadenectomy through a chest wall approach is technically feasible and safe with satisfactory cosmetic results. It may be a valid altern...
The surgical treatments of hepatocellular carcinoma (HCC) in a cirrhotic liver include both hepat... more The surgical treatments of hepatocellular carcinoma (HCC) in a cirrhotic liver include both hepatic resection and liver transplant. While the liver transplant is considered as a golden therapy, it has some obstacles including shortage of organs especially living donors, economic circumstances, and the progression of a tumor while waiting for the transplant so the second choice which is resection should have a role. In this study, 84 patients with HCC (who were legible for transplant according to Milan and extended selection criteria) were enrolled for hepatic resection. The outcome including complication and the oncologic outcome was evaluated. We followed our patients for 15 months as a median follow-up (range from 3 to 50 months); we noticed 10 tumor relapse (11.7%) and seven lost (8.3%). We also noticed no recurrence. Patients' overall survival showed a median of 15 and 50 months, respectively. We can conclude that there is reasonability for HR as an effective optional treatment for patients with HCC who are legible for transplant particularly for patients with a Child-A scoring.
Tongue resection is a surgical challenge because of its adverse effects on language articulation,... more Tongue resection is a surgical challenge because of its adverse effects on language articulation, swallowing, respiration, the eventual quality of life, and poor prognosis of advanced disease. To date, the currently accepted standard treatment has been based on excision of the primary lesion with a 1.5-2-cm circumferential macroscopic margin. Compartmental tongue surgery (CTS) is a surgical technique that removes an anatomo-functional compartment containing the primary tumor. This is a prospective study that was carried out from June 2012 to January 2015 for patients with carcinoma affecting oral tongue. We enrolled all cases with ≥T2 tongue cancer with or without infiltration of floor of the mouth. Patients underwent compartmental tongue resection with reconstruction using island submental flap. Pharyngeal tear occurred in two cases that were repaired by simple suture. Bleeding occurred in two cases with control of the affected vessels. Loco-regional recurrence was detected only in two cases that underwent CTS, while 18 patients who underwent traditional tongue resection had local recurrence. CTS via pull through technique with submental island flap reconstruction for large tongue cancer has been evolved to improve oncologic resections, obtaining a better local control of disease and increased survival rate with concomitant successful functional and esthetic outcomes especially in elderly patients with serious comorbidities.
Objective: Nerve blockade is commonly used in oncosurgical procedures as an alternative to genera... more Objective: Nerve blockade is commonly used in oncosurgical procedures as an alternative to general anesthesia for older patients and those with significant medical problems. We report a single tertiary oncology center experience in performing various lip resections and reconstructive techniques using this technique. Patients and methods: sixty patients with lower lip tumors were enrolled into this study with exclusion of refusing, non-compliant and critically ill patients. A solution of 4 ml 2% Lidocaine and epinephrine was put in a 5 ml syringe. Half the solution (2 ml) was injected into each side with a 23 gauge needle and after 5 minutes the surgical resection was carried out after testing for anesthesia. Results: The mean age was 68 ± 6.2 years. The mean ASA score was 3 ± 0.75. There were 4 cases who expressed painful sensation and their operations were completed with fentanyl increments. Mean hospital stay was 1 ± 0.75 days. There were three cases of wound gaping who were treated with secondary closure in an outpatient basis. One patient expressed postoperative acute ischemic heart pain that was managed with anti-ischemic measurements. Conclusion: Bilateral mental nerve block is a safe and effective alternative to general anesthesia in lower lip tumors' resection especially in older patients and those with poor tolerance for general anesthesia provided that there is no need for cervical nodal dissection.
Background: Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a d... more Background: Tumescent mastectomy refers to usage of a mixture of lidocaine and epinephrine in a diluting saline solution that makes flaps firm and tense, thus minimizing systemic drugs toxicity and making surgery possible with minimal bleeding. This technique is very useful in elder women and those with American Society of Anesthesiologists; score III and IV. The objective was to establish an alternative safe technique to general anesthesia in some selected mastectomy patients. Patients and methods: Twenty candidate women for total mastectomy and axillary dissection were enrolled and consented to participate. After preparation, an anatomically directed infiltration was made under sedation, using a cocktail of lidocaine, bupivacaine, and epinephrine, followed after 20 minutes by the surgical incision and completion of mastectomy. All intraoperative and postoperative outcomes were recorded. Results: Although 7 cases required added analgesic medications, no conversion for general anesthesia was recorded. Mean operative time was 81±15.8 minutes. Mean blood loss was 95.8±47.5 mL. There was no recorded intraoperative hemodynamic instability. Postoperative visual analog score was not exceeding 4 till the end of the first 24 hours. Opioids were not required in any case, and the mean dosage of Ketorolac used was 30±8.75 mg. Drains output and the incidence of postoperative complications were acceptable. Conclusion: We can consider tumescent mastectomy in well-selected patients a safe alternative for performing mastectomy when general anesthesia is hazardous, with minimal blood loss and long lasting postoperative analgesia without an additive effect on the operative time, hospital stay, and intraoperative and postoperative complications.
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Papers by Ashraf Khater