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Background Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. Methods A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. Results The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. Conclusion Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Background: The effects of Vagus Nerve preservation or division during One Anastomosis/Mini Gastric Bypass (OAGB/MGB) have not been studied before. The aim of this study was to compare Vagus Dividi...

Background: Overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life lost, and 3.8% of disability-adjusted life-years (DALYs) worldwide. Bariatric surgery is the most effective modality for long-term weight loss and for resolving the associated comorbidities. However, controversies exist regarding the ideal weight loss metabolic procedure. This allowed continuous search for new techniques.Aim of the work: to evaluate short-term outcomes and associated complications of laparoscopic sleeve gastrectomy with loop bipartition.Patients and Methods: The present study was conducted on fifteen patients who met the National Institute of Health criteria for bariatric surgery. These patients were enrolled in a prospective study at Ain-Shams University Hospitals from December 2015 to May 2017) and they underwent laparoscopic sleeve gastrectomy with loop bipartition. Preoperative work up included full history, full clinical examination, abdominal ultrasonography, biochemical labs. Procedure was performed by laparoscopic approach.Results: excess weight loss percentage at 6 months, 12 months respectively was 67%, 92%. This results were very comparable to mahdy et al. and santoro et al. Sleeve gastrectomy with loop bipartition comorbidities related outcomes were complete remission of 66% in T2DM, 71% in HTN, 100% others comorbidities and another studies for bipartition reached more than 90% in T2DM, 80% in HTN, 85% others comorbidities. In our study we recorded that Sleeve gastrectomy with loop bipartition has strong impact on resolution of comorbidities in comparison with BPD, DS, RYGB.Conclusion: Sleeve gastrectomy with loop bipartition is a new promising procedure that based on a new paradigm of helping GI facing and adapting to the modern diet without adding new morbidities with precise adsjusting of the neurohormonal aspects. Preliminary results points to potent simple safe procedure in treating obesity and metabolic syndrome.

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.

Our Study Aimed: To investigate the effect of laparoscopic sleeve gastrectomy (LSG) on obese T2DM patients, its effect in remission of diabetes and role of gastrointestinal Glucagon like peptide 1(GLP1) and Peptide tyrosine tyrosine (PYY) hormones. Metabolic surgery should be recommended as an option in type 2 diabetic patients (T2DM) with body mass index (BMI) ≥40 Kg/m2, in patients who have BMI ≥35 Kg/m2 and in selected patients with BMI < 35 Kg/m2, if not achieving diabetes control with maximum tolerated anti-hyperglycemic treatment. Methods: 30 T2DM patients with BMI ≥ 40 kg/m2 underwent laparoscopic sleeve gastrectomy after full clinical evaluation, routine blood tests, glucagon like peptide 1, Peptide tyrosine tyrosine (fasting, 0.5-hour post-mixed meal test (MMT) serum levels) and upper GIT endoscopy. Follow-up visits were at 3, 6 and 9 months postoperatively to evaluate body weight, BMI and glycated hemoglobin (HbA1C) and at 18th month for confirmation of diabetes remission. Gut hormones were measured at 15 days and 9 months postoperatively. Results: (53.3%) of patients had partial remission of T2DM according to HbA1C remission criteria. There was significant increase in fasting and post-MMT levels of peptide tyrosine tyrosine, glucagon like peptide 1 postoperatively. The only independent predictors for remission of T2DM were the baseline serum low density lipoprotein cholesterol (LDL-Ch), duration of diabetes, preoperative post MMT Peptide tyrosine tyrosine plasma level, serum thyroid stimulating hormone (TSH) and age. Conclusions: laparoscopic sleeve gastrectomy can induce partial remission of diabetes in younger patients who had shorter duration of diabetes, higher level of preoperative post-MMT peptide tyrosine tyrosine, lower levels of preoperative serum LDL-Ch and thyroid stimulating hormone.

Background It is already known that Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a stand-alone procedure with good short-term results for weight loss. However, in the long-term, weight regain is considered as a complication. Demand for secondary surgery is rising, partly for this reason, but through that study we try to discover the efficacy of conversion of failed sleeve gastrectomy to one anastomosis gastric bypass (OAGB) regarding weight loss and metabolic outcomes. Objective To asses the efficacy and safety of one anastomosis gastric bypass (OAGB) as a conversion surgery post Sleeve Gastrectomy failure as regard weight loss and metabolic outcomes. Patients and Methods This study is a retrospective cohort study which included 20 patients underwent one anastomosis gastric bypass at Ain-Shams University El-Demerdash Hospital, Cairo, Egypt and specialized bariatric center, Cairo, Egypt From February 2019 to July 2019 with 6 months of postoperative follow up till January 2019. Results In this study, we reviewed and analyzed the outcomes from the revision of the SG due to either inadequate weight loss or weight regain to one anastomosis gastric bypass (OAGB) with %EBWL of 6.65% at 1 month, 13.61 % at 3 months and 20.86% at 6 months. Conclusion OAGB appears to be an effective and safe therapeutic technique as a revisional surgery for failed primary SG with good short-term results for treating morbid obesity and its associated comorbidities with a significantly low rate of complications. However the EBWL was less than what is reported after primary OAGB weight. Multicenter studies with larger series of patients and longer term follow up after SG revisions to OAGB are warranted.

Background: About 10-30% of the SG patients are associated with long-term failure, due either to inadequate weight loss or to renewed weight gain. Objective: To compare weight loss as well as the metabolic effects of 2 types of bariatric surgery after failure of primary SG; Single Anastomosis Duodeno-ileal Bypass-Sleeve (SADI-S) and Mini- Gastric bypass (MGB), in the first year postoperative follow up. Patients and Methods: This study is a prospective controlled study which included 30 patients underwent bariatric and metabolic surgeries at Ain-Shams University El-Demerdash Hospital, Cairo,Egypt from July 2017 to July 2018 with one year of postoperative follow up till July 2019. A comprehensive assessment program was carefully structured so that a disciplined routine is followed in each patient. All patients were preoperatively evaluated with provision of extensive information and consented to participate in the study. Results: According to our results, the SADI-S group presented markedly higher percentage of EWL of 91.4% vs 71.6% in MGB afterone year. Control of DM, with HbA1c below 6%, was obtained in 86.6% in both groups with more decrease in mean HbA1c of SADIS being 5.44 vs 5.815% in MGB after one year. Most patients abandoned antidiabetic therapy or at least were controlled by less medications and lower doses. The SADI-S group presented remission of hypertension by 81.8% of patients vs 80% in MGB with far less medications. Lipid profile improvement was noticed in both groups with slightly higher resolution in SADIS group by 93.3% vs 86.6% for total cholesterol, 86.6% vs 80% for T.G, 80% vs 86.6% for LDL, 60% vs 67.6% for HDL in SADIS and MGB patients respectively. Although the nutritional deficiency is still a considerable concern after SADIS, ours study didn’t show intense difference from MGB provided that proper vitamin supplementation and patient compliance are maintained postoperatively. Conclusion: When compared to gastric bypass, SADI-S appearsto be an effective and safe therapeutic technique as a revisional surgery for failed primary SG with excellent short-term results for treating morbid obesity and its associated comorbidities with a low rate of nutritional complications. Proving its safety and efficacy by further studies and long term follow up will grant it more popularity in the future.

Summary: Background/Aims: Type 2 diabetes mellitus (T2DM) is considered a chronic progressive incurable metabolic disease. Single-anastomosis gastric bypass (SAGB) has proved to be effective in obese patients, yet its impact on non-obese diabetics is not extensively studied.The aim is to determine the anthropometric and glycemic outcomes of SAGB as a proposed line of treatment for T2DM patients with body mass index (BMI) 25–30 kg/m2. Methods: From November 2013 to March 2016, a prospective study has been conducted at Ain-Shams University Hospitals on 17 consecutive patients who have undergone SAGB. The demographic and anthropometric data, as well as the relevant laboratory results, were reported. Complete T2DM remission is considered if glycosylated hemoglobin (HbA1c)

Background Metabolic and bariatric surgery is a proven therapy for the treatment of obesity and its related comorbidities. Malabsorptive operations usually offer a higher rate of metabolic improvement, despite higher rate of complications and secondary effects. Objectives To compare Single Anastomosis Duodeno–Ileal bypass with Sleeve gastrectomy (SADIS) and Mini-Gastric Bypass operation as two types of bariatric surgeries with regard to weight loss, metabolic outcome and nutritional deficiencies within one year of post-operative follow up. Methods We performed a prospective comparison of 40 morbidly obese patients submitted to SADIS (n. = 20) and MGB (n. = 20) between July 2016 to July 2017 with one year of postoperative follow up. Results The groups were nearly similar in terms of age and sex. The SADI-S group had BMI of (47.4 vs 46.1) with 100% prevalence of DM in both groups, hypertension in SADIS 70% vs 65% in MGB and almost equal incidence of dyslipidemia. The SADI-S group presented markedly higher percentage of EWL of 91.4% vs 71.6% after one year. Control of DM, with HbA1c below 6%, was obtained in 85% in both groups with more decrease in mean HbA1c of SADIS being 5.44 vs 5.815 in MGB after one year. Most patients abandoned antidiabetic therapy or at least were controlled by less medications and lower doses. The SADI-S group presented remission of hypertension by 90% of patients as those of MGB but with far less medications. Lipid profile improvement was noticed in both groups with slightly higher resolution in SADIS group by 95% vs 90% for total cholesterol, 85% in both groups for T.G, 80% vs 85% for LDL, 65% vs 70% for HDL in SADIS and MGB patients respectively. Although the nutritional deficiency is still a considerable concern after SADIS, ours study didn’t show intense difference from MGB provided that proper vitamin supplementation and patient compliance are maintained postoperatively. Conclusion When compared to gastric bypass, SADI-S appears to be an effective and safe therapeutic technique with excellent short-term results for treating morbid obesity and its associated comorbidities with a low rate of nutritional complications. Proving its safety and efficacy by further studies will grant it more popularity in the future.

Background Colorectal cancer in Egypt has a higher incidence in young patients compared to western countries, where the disease is more prevalent in the old age group. This difference has been attributed to higher incidence of hereditary cancers in young Egyptian patients. The aim of this study is to compare the family history criteria and pathology features of tumors in young (≤40 years) and old (>40 years) Egyptian patients with adenocarcinoma of the colon and rectum. Materials and methods This is the analysis of our prospectively collected data on the pathology features of tumors in 313 consecutive patients (133 young, 180 old) with colorectal cancer presenting to the Department of Surgery within an eight-year period. A detailed family history was obtained from 258 patients (112 young, 146 old). Results 41 young and 48 old patients reported family history of cancer, the difference was not statistically significant. Ten young patients (9%) reported a family history of colorectal cancer in a first degree relative (3 fitting into Amsterdam criteria, 7 fitting into less strict criteria) which was not significantly different from the old age group. The pathologic features of tumors in both groups resembled sporadic rather than hereditary cancer and there was no significant difference between groups in tumor location, degree of differentiation, mucin production, synchronous and metachronous colorectal tumors or polyps and grossly stricturing or ulcerating tumors. Extracolonic tumors developed in one young and two old patients. Conclusion The characteristics of large bowel cancer in young Egyptian patients do not differ significantly from those in older patients. Despite the high incidence of large bowel cancer in young Egyptian patients, family history and pathologic features of tumors do not support a hereditary origin of colorectal cancer in this age group in Egypt.

Purpose: To describe the clinical experience with retinal vasculitis at 4 Egyptian tertiary eye centers. Methods: A multicenter retrospective chart review of all patients with retinal vasculitis encountered at 4 ocular inflammation referral clinics in Egypt between February 2013 and February 2018. Results: The study included 618 patients (327 males and 291 females). Of these, 284 patients had isolated retinal vasculitis, whereas 233 patients had an associated systemic inflammatory disease, the most frequent being Behcet's disease, followed by sarcoidosis. In 101 patients, retinal vasculitis could be attributed to an infectious etiology, and among this category, the most common was tuberculosis, followed by toxoplasmosis. Conclusion: In our Egyptian cohort, more than half the patients had their retinal vasculitis as part of a serious systemic disease, or as part of an infectious process, as tuberculosis. And in view of the significant potential morbidity of these conditions, the local ophthalmologists need to be aware of these entities when faced with patients presenting with retinal vasculitis.

Purpose: Single anastomosis sleeve ileal bypass (SASI) procedure appears as a new metabolic and bariatric surgery based on Santoro's operation, in which a sleeve gastrectomy is followed by a side–to-side gastroileal anastomosis. The study is aimed to evaluate the short-term outcomes of laparoscopic single anastomosis sleeve ileal bypass with respect to postoperative weight loss and metabolic and nutritional effects on patients. Methods: Forty-five morbidly obese patients with a mean age of 31.2 years and a mean body mass index (BMI) of 43.2 kg/m2 underwent SASI bypass. Postoperatively, all patients were followed up at 1, 3, 6, and 12 months, and during each visit data about their BMI, obesity-related comorbidities, and nutritional status were collected. Results: One year after the surgery, mean BMI decreased to 29.1 kg/m2 and there was significant decrease in plasma level of fasting blood glucose, insulin, and low-density lipoprotein. On the other hand, there was significant increase in high-densi...

Purpose: To report the clinical experience with scleritis at four Egyptian tertiary care eye centers. Methods: Multicenter retrospective chart review of all patients with scleritis visiting four ocular inflammation referral clinics in Egypt between January 2013 and October 2017. Results: A total of 303 scleritis patients were enrolled. These included 76 male and 227 female patients. The most frequent subtype of scleritis was nodular anterior scleritis (44.9%). Rheumatoid arthritis and Wegener granulomatosis were the 2 most common systemic associations among our cohort. Eyes with necrotizing scleritis with inflammation had the lowest mean initial and final BCVA. Conclusion: The visual prognosis of an eye with scleritis varies with the subtype of scleral inflammation. In our cohort, it was found to be poorer in eyes with necrotizing scleritis with inflammation compared to other subtypes.

Introduction: Bariatric procedures are widely spreading nowadays, laparoscopic sleeve gastrectomy is one of the most commonly performed Bariatric operations, post-operative bleeding is being a serious and a common event of this operation. Materials and methods: A retrospective analysis was performed for 80 out of 1500 patients, who underwent laparoscopic sleeve gastrectomy (LSG) in the period between March 2015 and August 2017. The rate of hemorrhagic complications was 5.3%, the mean age was 38.5 (± 8.718349), and the mean BMI was 40 (± 3.780856) Results: Source of bleeding was mostly intra-abdominal of which 95% of 76 patients, while intra-luminal bleeding represented only 5% of 4 patients. While in the intra-abdominal bleeding, 54 were there which had bleeding from the staple line, in 8 cases the bleeding was from the omentum, while 4 bled from the gastro-pancreatic adhesions, 4 bled from short gastric vessels, and in 6 patients the bleeding was from the trocar entry site. Conclusion: Early re-laparoscopy after post-LSG bleeding is diagnostic and therapeutic, and decreases both morbidity and mortality of patients.

Background Recently, it is being suggested in the literature that postoperative pain after TAPP is mostly attributed to the use of staples in mesh fixation .This study aims to compare the value and cost effectiveness of using facial closure needle versus the use of staples in the fixation of prosthetic meshes in laparoscopic tinguinal hernia repair (TAPP). Methods Sixty male patients suffering from inguinal hernia with a mean age 22.7 years ranging from 18 to 30 years were enrolled in this study mesh fixation using fascial closure needle was done in 30 cases and using staples in another other 30 cases. Full physical assessment for the patients was performed and any postoperative complications such as early or late post-operative pain or burning sensation, hyperesthesia, wound infection, seroma, hematoma or recurrence were recorded. Results he mean duration of intervention for fascial needle fixation cases was 43.4 minutes while for stapled cases the mean duration of intervention was 40 minutes. The mean recovery time to normal physical activity was 7.5 days for fascial needle fixation cases and was 9.1 for stapled cases. In stapled patients, one case of recurrence occurred, 2 cases showed hematoma and by the end of the 1st month after the operation, 2 cases had suffered lateral thigh pain, while at the end of the 6th month after the operation 5 cases had suffered chronic inguinal pain. In cases with fascial needle fixation no recurrence had occurred, while 1 case showed subcutaneous port hematoma and one case was reported with inguinal discomfort at the end of the 1st month after the operation and at the end of the 6th month after the operation, no cases had pain Conclusion From the above results, we can conclude that the use of fascial needle closure for mesh fixation in TAPP is better than the use of staples, not only because it is associated with lower incidence of postoperative complications (i.e. postoperative pain and recurrence) but also because its associated with lower costs allowing better availability for all patients

Background :Morbid Obesity (BMI > 40 kg/m2) is a substantial health problem that is related to many metabolic disorders including diabetes, hypertension and hypercholesterolemia and several cardiovascular diseases. This study we aimed to investigate the early metabolic changes which occur after Laparoscopic Sleeve Gastrectomy. Methods: One hundred morbid obese patients (65 females and 35 males) aged between 18 to 50 years with BMI range between 40-50 kg/m2 were enrolled in this study. Patients were followed up after 3 and 6 months post operation to monitor their BMI, serum glucose level, insulin, serum cholesterol level, triglycerides and systolic blood pressure. Results :A significant correlation was found between the percent decrease in BMI and the percent decrease in the measured metabolic parameters especially cholesterol and triglycerides levels at three and six months postoperatively. Conclusion: From the above results we can conclude that LSG is not only an effective bariatric procedure for loss of weight but also it plays and important and effective role in correction of metabolic disturbance associated to obesity especially diabetes type 2 very early after the operation. Statistically analysis used: Continuous variables are expressed as mean and Standard Deviation. Categorical variables are expressed as frequencies and percent. All statistical procedures were carried out using SPSS version 15 for Windows (SPSS Inc, Chicago, IL, USA).

Background. Long-term studies have reported that the rate of conversion surgeries after open VBG ranged from 49.7 to 56%. This study is aiming to compare between LMGB and LRYGB as conversion surgeries after failed open VBG with respect to indications and operative and postoperative outcomes.Methods. Sixty patients (48 females and 12 males) presenting with failed VBG, with an average BMI of 39.7 kg/m2ranging between 26.5 kg/m2and 53 kg/m2, and a mean age of 38.7 ranging between 24 and 51 years were enrolled in this study. Operative and postoperative data was recorded up to one year after the operation.Results. MGB is a simple procedure that is associated with short operative time and low rate of complications. However, MGB may not be applicable in all cases with failed VBG and therefore RYGB may be needed in such cases.Conclusion. LMGB is a safe and feasible revisional bariatric surgery after failed VBG and can achieve early good weight loss results similar to that of LRYGP. However, the decision to convert to lap RYGB or MGB should be taken intraoperatively depending mainly on the actual intraoperative pouch length.

Background In laparoscopic sleeve gastrectomy (LSG), the patients may experience serious postoperative complications such as hemorrhage or leakage. The aim of this study was to evaluate the benefit of routine omentopexy (RO) to staple line in decreasing postoperative hemorrhage and leakage. Patients and methods A retrospective cohort study analyzing prospectively collected data including 2000 LSG from March 2015 to December 2017. The patients were evenly divided into two groups: Group A of 1000 LSG with no omentopexy (NO) and group B of 1000 LSG with RO to staple line with full thickness stitches till the level of the incisura above. Results The mean age was 33.2±15.7 and 30±10.9 for group A (NO) and group B (RO), respectively. The mean BMI in group A is 45±7, while it is 46±9 in group B. Staple line leakage occurred in 9 cases (0.9%) of group A, while none (0.0%) of the group B patients experienced evidence of leakage (P=0.003). In group A, 26 cases were diagnosed to have significant postoperative bleeding, compared with only eight (0.8%) patients of group B (P=0.003). Perigastric localized collection was found in three (0.3%) cases and only one case in the two groups (P=0.625). The operative time spent in group A was 55±20 min, much lower than that in group B which was 85±35 (P=0.001). The mean hospital stay was 30±18 and 24±12 in group A and Group B, respectively (P=0.001). Conclusion RO to staple line has shown to be effective in decreasing staple line bleeding and leakage and hospital stay, although it prolongs the operative time.