Background: Modified radical mastectomy (MRM) is the most common surgery for cancer breast that is associated with marked postoperative pain. Effective control of this pain suppresses the surgical stress response and decreases the opioids and general anesthetics’ needs. This study compared the erector spinae plane (ESP) block and the pectoral plane (PECS) block effects on the opioid consumption postoperatively, stress response, fentanyl needs intraoperatively, pain scores, and incidence of complications in female patients subjected to MRM surgery. Patients and Methods: Fifty patients were allocated randomly and divided into two groups. Forty-seven patients were included in the final analysis after exclusion. ESP block group (E group, n = 24) received 20 mL of 0.25% levobupivacaine plus 0.5 μ/kg dexmedetomidine that was injected in-between erector spinae muscle and transverse process. PECS block group ( P group, n = 23) received 30 mL of 0.25% levobupivacaine plus 0.5 μg/kg dexmedetomidine divided into 10 mL that was injected between the two pectoralis muscles in the interfascial plane and the other was 20 mL injected between the serratus anterior and the pectoralis minor. Results: Postoperative morphine consumption and stress hormone level in P group were significantly lower than E group. The pain scores and number of patients requested analgesic postoperatively showed significantly higher values in E group. Hemodynamic parameters, fentanyl needed intraoperatively and the incidence of postoperative complications recorded no significant difference between the two groups. Conclusion: The current study demonstrated that PECS block provides better quality of analgesia than ESP block in patients subjected to MRM operations.

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Introduction: Endoscopic thyroidectomy (ET) has become a well-established surgical technique that is mainly performed for benign thyroid lesions. Several endoscopic approaches are available, such as transaxillary, unilateral axillo-breast approach (UABA), modified anterior chest wall approach (MACWA), bilateral axillo-breast approach, and most recently the transoral approach and the robotic-assisted techniques. There is no recommended approach, because each approach has its own positive and negative attributes. We, herein, compare between UABA and MACWA in terms of surgical and cosmetic outcomes. Methods: This prospective study was conducted from April 2016 to August 2017. Forty patients with unilateral benign thyroid lesions were selected. Of them, 20 patients underwent ET using UABA, and 20 patients underwent ET using MACWA. Gas insufflation was implemented for all patients. Clinicopathologic data, surgical outcomes, and cosmetic outcomes in both groups were analyzed. Results: There was no significant difference between both groups in the clinicopathologic characteristics. The mean surgical time was significantly longer in the UABA group compared with the chest wall group (147.3 vs. 124.3 min). The postoperative pain scores were relatively lower in the UABA group compared with the MACWA group. We reported a higher rate of persistent paresthesia, neck contracture with swallowing discomfort, and hypertrophic scars in the MACWA group. Cosmetic satisfaction scores for patients who underwent UABA were higher than for those who underwent MACWA. Conclusions: Both approaches were similar in terms of safety, feasibility, and operative complications. Even though the surgical time was longer, patients who underwent the UABA reported relatively less postoperative pain, superior cosmetic results, scar perception, and patient satisfaction compared with MACWA.

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Purpose: The study aims to assess the functional outcome of anal sphincter-sparing procedures (SSP) with total mesorectal excision (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. Using the per anal examination scoring system (PASS), postoperative anal function was assessed after 1 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 of 67 cases). The PASS findings of 69 cases are as follows: extremely hypotonic 8.6% (6 cases), slightly hypotonic 26.1% (18 cases), normal tone 58% (40 cases), slightly stenotic 3 cases (4.3%), or occluded 2.9% (2 cases). Urinary dysfunction occurred in 1 case (1.4%). Temporary diversion was performed in 61 patients (87.1%).Conclusion: Sphincter preservation with TME for anorectal adenocarcinoma helps avoid permanent stoma and provides reasonable functional outcomes. PASS is a new application for postoperative assessment of anal function.

Background P D-L1 is expressed in tumor cells and plays a crucial role in tumor immune escape. Tumor-infiltrating lymphocytes (TILs) as CD8 T cells contribute to reduced tumor growth. Few studies investigated the prognostic effect of PD-L1 and CD8 TILs in ovarian high-grade serous carcinoma (HGSC). In the present study, we analyzed the expression of PD-L1 and CD8 TILs in HGSC by immunohistochemistry, and results were correlated to prognosis. It was carried on 54 cases of ovarian HGSC who attended the Oncology Centre, Mansoura University, Egypt, from 2012 till 2019. Results Nearly 60% of cases showed positive PD-L1 expression in tumor cells. Regarding the clinicopathological characteristics, higher PD-L1 expression was found among patients with residual tumor (82.4%) compared to patients with no residual tumor (54.5%), with marginal statistical significance (p 0.07). PD-L1 was significantly associated with CD8 TILs expression. Higher PD-L1 expression was found among tumors with low expression of CD8 TILs with statistically significant difference (p≤0.001). Disease-free survival (DFS) was significantly lower among the group with positive expression of PD-L1 compared to the group with negative expression of PD-L1 (p 0.01), while overall survival (OS) was not associated with PD-L1 expression. On the other hand, the overall survival (OS) in patients with high CD8 expression was significantly higher than patients with low CD8 expression (p 0.043), while DFS was not significantly different among both CD8 TILS groups. Conclusions PD-L1 and CD8 TILs may become a promising therapeutic target for patients with ovarian HGSC. More studies are needed to further validate their prognostic effect. Precise identification of patients who will benefit from PD-L1 checkpoint blockade and TILs adaptive immunotherapy is mandatory.

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ObjectivesPercutaneous nephrolithotomy (PCNL) is the standard management for large and/or complex urolithiasis, but the standard patient position for PCNL is undecided. With the patient prone PCNL has several drawbacks, while when supine, as described previously, PCNL has mechanical limitations. We describe a modification that aims to overcome these limitations and provide easy access comparable to that in the prone position.Patients and methodsThis prospective study was carried out at the Urology Department, Zagazig University, Egypt, from October 2008 to March 2011, and included 78 patients (48 men and 30 women). First the patient was placed supine and then in the ‘flank-free modified’ supine position. The distance between the last rib and the iliac crest in the posterior axillary line was measured in both positions.ResultsThe mean age of the patients was 40.8 years, the mean (SD) stone diameter was 3.4 (0.7) cm, the number of right/left stones was 34/44, and mean body mass index was 28.8 kg/m2. The mean (SD) increase in the distance between the last rib and the iliac crest in the posterior axillary line in the flank free modified supine position vs. the previous supine position was 12 (0.8) mm.ConclusionThe flank-free modified supine position increases the distance between the last rib and the iliac crest, and, together with the absence of a cushion under the flank, provides ample space for puncture, dilatation, multiple tracts and manoeuvrability of the system with the nephroscope.