Background
The pancreatic leak is the most dangerous complication
postpancreaticoduodenectomy. There are many risk factors for the development
of pancreatic fistula (PF) such as texture of the pancreas and its duct size.
The aim was to decrease the incidence of PF in these risky patients.
Patients and methods
A retrospective study was performed on 20 periampullary tumors patients treated
by subtotal pancreatectomy between April 2015 and September 2017, which were
performed in Assiut Al Rajhi Liver Hospital. Subtotal pancreatectomy was
performed in patients with soft pancreas which could not hold stitches and small
duct size of less than 3 mm. Also, the authors follow the results of postoperative
pancreatic leakage, other morbidity and mortality.
Results
A PF type A developed in three cases and did not require any further management,
one case developed PF type B who also developed delayed gastric emptying and
improved after 3 months; one case of abdominal abscess was managed by
insertion of pig tail; two cases of wound infection improved by repeated
dressing; the mean hospital stay was 7 days except for the patient who
developed PF type B and delayed gastric emptying whose hospital stay was
prolonged to 1 month; the mortality rate was one case, who was a female
patient of 70 years old and died by myocardial infarction 1 week postoperatively.
Conclusion
Subtotal pancreatectomy with stapling can be done safely in risky patients to
decrease the incidence of PF, but further large randomized trials are needed.
Keywords:
pancreatic fistula, periampullary tumors, subtotal pancreatectomy

Background: Terlipressin, in general, is a vasopressor which acts via V1 receptors. Its infusion elevates mean blood
pressure and can reduce bleeding which has a splanchnic origin. The primary outcome was to assess the impact of
intraoperative terlipressin infusion on portal venous pressure during hepatobiliary surgery; the 2ry outcomes
included effects upon systemic hemodynamics, estimated blood loss, and postoperative renal functions.
Methods: This prospective randomized study involved 50 patients undergoing hepatobiliary surgery who were
randomly and equally allocated into terlipressin group, or a control group. The terlipressin group received an initial
bolus dose of (1 mg over 30 min) followed by a continuous infusion of 2 μg/kg/h throughout the procedure and
gradually weaned over the first four postoperative hours, whereas the control group received the same volumes of
normal saline. The portal venous pressure changes were measured directly through a portal vein angiocatheter.
Results: Portal pressure was significantly reduced over time in the terlipressin group only (from 17.88 ± 7.32 to
15.96 ± 6.55 mmHg, p < .001). Mean arterial blood pressure was significantly higher in the terlipressin group.
Estimated blood loss was significantly higher in the control group than the terlipressin group (1065.7 ± 202 versus
842 ± 145.5 ml; p = 0.004), and the units of packed RBCs transfused were significantly higher in the control group
((0–2) versus (0–4) p = 0.003). There was no significant difference between groups as regards the incidence of acute
kidney injury.
Conclusion: Intraoperative infusion of terlipressin during hepatobiliary surgery was shown to improve
intraoperative portal hemodynamics with subsequent reduction in blood loss.
Trial registration: Clinical trial number and registry URL: Trial registration number: NCT02718599. Name of registry:
ClinicalTrials.gov. URL of registry: https://clinicaltrials.gov/ct2/show/NCT02718599. Date of registration: March 2016.
Date of enrolment of the first participant to the trial: April 2016.
Keywords: Terlipressin, Portal pressure, Hemodynamics, Blood loss

Context
Multivisceral resections including Whipple procedure are among the foremost common
oncologic procedures during which massive bleeding and transfusion might happen
intraoperatively or postoperatively. Terlipressin is a synthetic vasopressin analog with relative
specificity for the splanchnic circulation where it causes vasoconstriction, with a hypothetical
reduction in blood loss during abdominal surgeries.
Aims
We aim to assess the effect of terlipressin infusion on blood loss and blood transfusion
requirements during Whipple procedure.
Settings and design
The current study was a prospective single center randomized placebo‑controlled trial. The
study was carried out in Al Rajhy Liver Hospital, Assiut University, Egypt between May 2016
and July 2017.
Patients and methods
In this trial 40 patients scheduled for Whipple procedure were randomly assigned either to
receive terlipressin at the beginning of surgery as an initial bolus dose of (1 mg over 30 min)
followed by a continuous infusion of 2 μg/kg/h throughout the procedure and gradually weaned
over the first 4 h postoperatively (terlipressin group) or to receive the same volume and rate
of 0.9% saline for the same duration (control group).The primary outcome was the amount
of intraoperative blood loss.
Statistical analysis used
Statistical analysis was established using SPSS, version 16.0.
Results
The amount of intraoperative blood loss was significantly lower in the terlipressin
group (690.00 ± 449.44) in comparison with the control group (1020.00 ± 284.88). Five (25%)
patients received blood transfusion in the terlipressin group compared with 13 (65%) patients
in the control group (P = 0.011). Significantly greater number of packed red blood cells units
were transfused to the control group (P = 0.013).
Conclusion
Terlipressin infusion during Whipple procedure was associated with less bleeding and lower
rates of blood transfusion requirements compared with placebo.
Keywords:
blood loss, terlipressin, transfusion needs, Whipple procedure

Abstract
Background
Scarcity of published research that comprehensively and meticulously analyzed the patient, disease, and treatment factors of prognostic significance in Ewing sarcoma (EWS) in Egypt.
Aim
To assess survival outcomes of EWS in Upper Egypt, delineating factors of prognostic significance in comparison to other leading oncology centers in Egypt and internationally.
Methods
We retrospectively reviewed medical records of 85 patients with a verified diagnosis of EWS at Pediatric Oncology department and Medical Oncology department at South Egypt Cancer Institute to gather data relevant to the patient, disease, and treatment variables of the study in the period from 2001 to 2015. Survival was estimated using the Kaplan Meier method and differences between various groups were determined by log rank test. Univariable and multivariable analyses were performed using Cox regression.
Results
With a median follow-up period of 62.7 months (95CI% 52.2-73.2, SE= 5.4) for the study patients, the estimates of event-free survival (EFS) and overall survival (OS) at 3 and 5 years were 42.1% and 50.6%, and 40.8% and 48.5%, respectively. Metastatic disease at initial presentation (HR=8.91, 95%CI, 4.00-19.9; P< 0.0001) stood as the most powerful predictor of OS in the multivariable analysis, followed by surgery used as a local modality (HR=0.16, 95%CI, 0.06-0.44; P= 0.0004). Response to neoadjuvant chemotherapy (HR=2.61, 95%CI, 1.11-6.13; P= 0.028), primary tumor size (HR=2.49, 95%CI, 1.03-6.03; P= 0.044) were also shown to be significantly associated with OS. Radiotherapy as a local modality, whose effect, apparently shown to increase the hazard of events occurrence in the univariable analysis, an effect that was reversed to reveal EFS advantage (HR=0.41, 95%CI, 0.18-0.95; P= 0.036) after control of other variables.
Conclusion
With 5-year OS of 48.5%, our survival results were comparable to those previously published from Egypt; however, differences still exist between centers due to varied representative study samples. However, outcomes in Egypt in general are still inferior to internationally published studies

We have updated the dataset of the molecular spectrum of the β-thalassemia (β-thal) in Upper
Egypt. Buccal swabs were analyzed from 94 unrelated patients with β-thal major (β-TM) using
reverse dot-blot and multiplex amplification refractory mutation system-polymerase chain reaction
(ARMS-PCR). The most frequent mutation was IVS-I-110 (G>A) (57%). The IVS-I-110, IVS-I-6
(T>C) and IVS-I-1 (G>A) mutations accounted for 87% of the β-thal anomalies. The codon 39
(C>T) and frameshift codon (FSC) 6 (–A) (GAG>–GG) mutations were only detected in Al-Minya
and Qina, respectively. We did not observe the IVS-II-745 (C>G) or –101 (C>T) mutations. Fortythree
percent of Upper Egyptians were homozygotes. Our efforts were an important step to complete
the mutation map of β-thal in Egypt restricted to Cairo and the Nile Delta regions. This study will
help to develop preventative programs for Upper Egyptians. It addressed the genetic drift of the β-thal
gene mutations in Africa, Asia, and Europe.

Background: Inborn errors of metabolism are genetically inherited diseases which can lead to accumulation of toxic metabolites in the body. Inborn errors of metabolism have a high morbidity and mortality in neonates. Many inborn errors of metabolism are amenable to treatment with early diagnoses. Till now, more than 500 metabolic disorders have been detected. Although individual metabolic disorders are rare, the incidence of overall metabolic disorders is high. Results: It was found that 70/200 cases (35 %) had confirmed inborn errors of metabolism, and another 8 cases (4%) suspected to have inborn errors of metabolism; 15/200 (7.5%) cases had mild elevation of phenylalanine level, while 107/200 (53.5%) had another diagnosis rather than metabolic disorders. Urea cycle defect was diagnosed in 20/70 (28.5%), maple syrup urine disease in 18/70 (25.7%), organic acidemia in 15/70 (21.4%), and non-ketotic hyperglycinemia in 1/70 (1.4 %) case. Also, 15/70 (21.4 %) cases had fatty acid oxidation defect. Lastly, one female case (1.4 %) was diagnosed to have disorder of pyrimidine deficiency. Conclusion: Diagnosis of inborn errors of metabolism was confirmed in 35% of neonates, and 4% was suspected to have metabolic disorders. These results showed that inherited metabolic disorders are not rare. The development of a nationwide screening program for metabolic disorders is mandatory for early detection of these potentially treatable disorders. Keywords: Neonatal screening, Inborn errors of metabolism (IEM), Metabolic disorders, Aminoacidopathies, Fatty acid oxidation defects, Tandem mass spectrometry.

Background: Our study aimed to evaluate the clinical utility of detecting plasma
microRNAs (miR-21 & miR-92a) for diagnosis of colorectal cancer patients and its
relation to tumor staging. Patients and Methods: Quantitative real-time RT-PCR was
applied to determine the relative expression level of miR-21 and miR-92a in serum.
The sensitivity and specificity of these markers were evaluated by receiver operating
characteristic (ROC) curve analysis. Final staging of colorectal cancer cases was
assigned according to results of histopathologic examination of surgically resected
specimens. Results: This study included 52 cases of colorectal cancer (CRC), 20 cases
of precancerous colorectal lesions, and 20 healthy controls. Both Plasma miR-21 and
Plasma miR-92a were significantly higher in CRC group compared to both the control
group and precancerous group. Also, they were significantly higher in advanced CRC
stages than early CRC stages. The sensitivity and specificity of miR-21 for
discriminating CRC from controls were found to be 90.38% and 100.0%, respectively.
However, for miR-92a, sensitivity and specificity were found to be 94.23% and
100.0%, respectively. For discriminating CRC cases from precancerous lesions, the
sensitivity and specificity of miR-21 were found to be 75.08% and 95.0%,
respectively. However, for miR-92a, sensitivity and specificity were found to be
80.77% and 100.0%, respectively. Conclusions: both plasma miR-21 and miR-92a
have significant value for early detection of CRC as non-invasive screening molecular
biomarkers with high sensitivity and specificity. They also help for differentiation
between patients with benign and malignant colorectal lesions and those with early
and advanced CRC.

Background

The Radiological Society of North America (RSNA) recently published a chest CT classification system and Dutch Association for Radiology has announced Coronavirus disease 2019 (COVID-19) reporting and data system (CO-RADS) to provide guidelines to radiologists who interpret chest CT images of patients with suspected COVID-19 pneumonia. This study aimed to compare CO-RADS and RSNA classification with respect to their sensitivity and reliability for diagnosis of COVID-19 pneumonia.

Results

A retrospective study assessed consecutive CT chest imaging of 359 COVID-19-positive patients. Three experienced radiologists who were aware of the final diagnosis of all patients, independently categorized each patient according to CO-RADS and RSNA classification. RT-PCR test performed within one week of chest CT scan was used as a reference standard for calculating sensitivity of each system. Kappa statistics and intraclass correlation coefficient were used to assess reliability of each system. The study group included 359 patients (180 men, 179 women; mean age, 45 ± 16.9 years). Considering combination of CO-RADS 3, 4 and 5 and combination of typical and indeterminate RSNA categories as positive predictors for COVID-19 diagnosis, the overall sensitivity was the same for both classification systems (72.7%). Applying both systems in moderate and severe/critically ill patients resulted in a significant increase in sensitivity (94.7% and 97.8%, respectively). The overall inter-reviewer agreement was excellent for CO-RADS (κ = 0.801), and good for RSNA classification (κ = 0.781).

Conclusion

CO-RADS and RSNA chest CT classification systems are comparable in diagnosis of COVID-19 pneumonia with similar sensitivity and reliability.

Background

A major role of CT in COVID-19 pneumonia is to assess disease severity and progress. In this study, we aimed to assess the validity, reliability, and survival outcomes of simple chest computed tomography (CT) score in the evaluation of the severity of lung involvement in coronavirus disease 2019 (COVID-19) compared with the current chest CT score.

Results

This retrospective analysis included 213 patients (121 men and 92 women; mean age, 46 ± 15.6 years; range, 1–85 years). The ROC curve was used to compare the validity of both scores. Interreader agreement (IRA) for both scores was calculated using Cohen’s kappa statistic. The survival analysis of both scores was investigated using the Kaplan–Meier survival analysis. The simple score showed a comparable validity with the current score (AUC = 0.89 and 0.90, respectively; p = 0.61). The ROC analysis demonstrated that a simple score of > 3 and a current score of > 12 were potential predictors of death with sensitivity values of 81.8% and 86.4% and specificity values of 96.3% and 93.7%, respectively. The simple score showed a higher IRA compared with the current score (κ = 0.645 and 0.458, respectively). Both scores were comparable for predicting survival outcomes.

Conclusion

The simple score was non-inferior for predicting survival outcome, compared with the current chest CT score. Furthermore, we suggest that the simple score should be used as it is simpler and more consistent.