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Article: Effects of Dexamethasone and Pentoxifylline on Mania-like and Depression-like Behaviors in Rats.

Nassar, Ahmad / Azab, Abed N

2022 Volume 15, Issue 9

Abstract: Several studies support the notion that inflammation plays a role in the pathophysiology and treatment approaches of psychiatric illnesses, particularly mood disorders. Congruently, classic anti-inflammatory drugs were found efficacious in randomized ... ...

Abstract	Several studies support the notion that inflammation plays a role in the pathophysiology and treatment approaches of psychiatric illnesses, particularly mood disorders. Congruently, classic anti-inflammatory drugs were found efficacious in randomized clinical trials of patients with mood disorders. Moreover, accumulating data indicate that psychotropic drugs exhibit some anti-inflammatory effects. This study was undertaken to examine the efficacy of dexamethasone (a potent corticosteroid) and pentoxifylline (a methylxanthine drug with proven anti-tumor necrosis factor-α inhibitory activity) in behavioral models in rats, which were treated intraperitoneally with either dexamethasone or pentoxifylline for two weeks and then subjected to a battery of behavioral tests. Treatment with pentoxifylline, but not dexamethasone, was associated with antidepressant-like and anti-manic-like effects. The beneficial behavioral effects of pentoxifylline were accompanied by a prominent reduction in pro-inflammatory mediator levels in the brain. For the first time, the current work proves the efficacy of pentoxifylline against both mania-like and depressive-like behaviors. These results suggest that pentoxifylline may be a promising therapeutic intervention for patients with mood disorders. Taking into account the excellent tolerability profile of pentoxifylline in humans, it is warranted to conduct randomized clinical trials to investigate its therapeutic efficacy in patients with psychiatric disorders.
Language	English
Publishing date	2022-08-26
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2193542-7
ISSN	1424-8247
ISSN	1424-8247
DOI	10.3390/ph15091063
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Article ; Online: The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients.

Welsh, Silje / Nassar, Ahmad H M / Sallam, Mahmoud

Surgical endoscopy

2022 Volume 36, Issue 11, Page(s) 8221–8230

Abstract: Background: The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two- ... ...

Abstract	Background: The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management. Methods: Analysis of prospectively maintained data in a unit adopting a policy of "intention to treat" during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications and postoperative outcomes with patients who underwent index admission LC. Results: Of the 5750 LC performed, 20.8% had previous biliary episodes resulting in one admission in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p < 0.001), longer operating times (86.9 vs. 68.1 min, p < 0.001), more postoperative complications (7.8% vs. 5.4%, p = 0.002) and longer hospital stay (8.1 vs. 5.5 days, p < 0.001) and presentation to resolution intervals. However, conversion and mortality rates showed no significant differences. Conclusion: Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of the presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and postoperative outcomes of biliary emergencies.
MeSH term(s)	Humans ; Bile Ducts/surgery ; Cholecystectomy, Laparoscopic/adverse effects ; Cholecystectomy, Laparoscopic/methods ; Cholecystitis, Acute/surgery ; Incidence ; Treatment Outcome ; Time-to-Treatment ; Prospective Studies
Language	English
Publishing date	2022-05-04
Publishing country	Germany
Document type	Journal Article
ZDB-ID	639039-0
ISSN	1432-2218 ; 0930-2794
ISSN (online)	1432-2218
ISSN	0930-2794
DOI	10.1007/s00464-022-09272-0
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Article ; Online: Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies.

Nassar, Ahmad H M / Ng, Hwei Jene

Langenbeck's archives of surgery

2021 Volume 407, Issue 1, Page(s) 213–223

Abstract: Purpose: The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid ... ...

Abstract	Purpose: The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. Methods: A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. Results: Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. Conclusion: Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.
MeSH term(s)	Bile ; Bile Ducts/surgery ; Cholecystectomy, Laparoscopic/adverse effects ; Cystic Duct/surgery ; Humans ; Incidence
Language	English
Publishing date	2021-08-26
Publishing country	Germany
Document type	Journal Article
ZDB-ID	1423681-3
ISSN	1435-2451 ; 1435-2443
ISSN (online)	1435-2451
ISSN	1435-2443
DOI	10.1007/s00423-021-02264-z
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Article ; Online: Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients.

Ng, Hwei Jene / Nassar, Ahmad H M

Surgical endoscopy

2021 Volume 36, Issue 5, Page(s) 2809–2817

Abstract: Background: Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients' quality of life and may lead to reinterventions. This ... ...

Abstract	Background: Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients' quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE. Methods: A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined. Results: Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths. Conclusion: This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.
MeSH term(s)	Bile Ducts ; Cholangiopancreatography, Endoscopic Retrograde/methods ; Cholecystectomy, Laparoscopic/adverse effects ; Cholecystectomy, Laparoscopic/methods ; Choledocholithiasis/complications ; Common Bile Duct/surgery ; Female ; Gallstones/surgery ; Humans ; Male ; Middle Aged ; Prospective Studies ; Quality of Life
Language	English
Publishing date	2021-06-02
Publishing country	Germany
Document type	Journal Article ; Review
ZDB-ID	639039-0
ISSN	1432-2218 ; 0930-2794
ISSN (online)	1432-2218
ISSN	0930-2794
DOI	10.1007/s00464-021-08568-x
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Article ; Online: Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration.

Nassar, Ahmad H M / Khan, Khurram S / Ng, Hwei J / Sallam, Mahmoud

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract

2022 Volume 26, Issue 9, Page(s) 1863–1872

Abstract: Objectives: The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes ... ...

Abstract	Objectives: The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload. Methods: A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group. Results: A total of 683 patients (14.5%) had a mean BMI of 39.9 (35-63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates. Conclusions: This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.
MeSH term(s)	Bile Ducts ; Cholecystectomy, Laparoscopic/adverse effects ; Cholecystectomy, Laparoscopic/methods ; Choledocholithiasis/surgery ; Common Bile Duct/surgery ; Female ; Humans ; Morbidity ; Mortality ; Obesity, Morbid/surgery ; Retrospective Studies
Language	English
Publishing date	2022-05-31
Publishing country	United States
Document type	Journal Article
ZDB-ID	2012365-6
ISSN	1873-4626 ; 1934-3213 ; 1091-255X
ISSN (online)	1873-4626 ; 1934-3213
ISSN	1091-255X
DOI	10.1007/s11605-022-05344-7
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Zs.A 5207: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (2.OG) ab Jg. 2022: Lesesaal (EG)
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Article ; Online: The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones.

Nassar, Ahmad H M / Qandeel, Haitham / Khan, Khurram S / Ng, Hwei J / Hasanat, Subreen / Ashour, Haneen

Updates in surgery

2023 Volume 75, Issue 7, Page(s) 1893–1902

Abstract: The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study ...

Abstract	The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.
MeSH term(s)	Humans ; Retrospective Studies ; Cholecystectomy, Laparoscopic/methods ; Gallstones/diagnostic imaging ; Gallstones/surgery ; Cholangiography/methods ; Bile Ducts ; Catheters
Language	English
Publishing date	2023-08-04
Publishing country	Italy
Document type	Journal Article
ZDB-ID	2572692-4
ISSN	2038-3312 ; 2038-131X
ISSN (online)	2038-3312
ISSN	2038-131X
DOI	10.1007/s13304-023-01610-8
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Article ; Online: A proposed difficulty grading system for laparoscopic bile duct exploration: benefits to clinical practice, training and research.

Nassar, Ahmad H M / Sallam, Mahmoud / Khan, Khurram S / Kilpatrick, Rhona / Zino, Samer / Katbeh, Tarek Z

Surgical endoscopy

2023 Volume 37, Issue 9, Page(s) 7012–7023

Abstract: Background: A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate ... ...

Abstract	Background: A gap remains between the mounting evidence for single session management of bile duct stones and the adoption of this approach. Laparoscopic bile duct exploration (LBDE) is limited by the scarcity of training opportunities and adequate equipment and by the perception that the technique requires a high skill-set. The aim of this study was to create a new classification of difficulty based on operative characteristics and to stratify postoperative outcomes of easy vs. difficult LBDE irrespective of the surgeon's experience. Methods: A cohort of 1335 LBDEs was classified according to the location, number and size of ductal stones, the retrieval technique, utilisation of choledochoscopy and specific biliary pathologies encountered. A combination of features indicated easy (Grades I and II A & B) or difficult (Grades III A and B, IV and V) transcystic or transcholedochal explorations. Results: 78.3% of patients with acute cholecystitis or pancreatitis, 37% with jaundice and 46% with cholangitis had easy explorations. Difficult explorations were more likely to present as emergencies, with obstructive jaundice, previous sphincterotomy and dilated bile ducts on ultrasound scans. 77.7% of easy explorations were transcystic and 62.3% of difficult explorations transductal. Choledochoscopy was utilised in 23.4% of easy vs. 98% of difficult explorations. The use of biliary drains, open conversions, median operative time, biliary-related complications, hospital stay, readmissions, and retained stones increased with the difficulty grade. Grades I and II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusion: Difficulty grading of LBDE is useful in predicting outcomes and facilitating comparison between studies. It ensures fair structuring and assessment of training and progress of the learning curve. LBDEs were easy in 72% with 77% completed transcystically. This may encourage more units to adopt this approach.
MeSH term(s)	Humans ; Gallstones/surgery ; Laparoscopy/methods ; Common Bile Duct/surgery ; Bile Ducts/surgery ; Catheterization ; Cholecystectomy, Laparoscopic ; Choledocholithiasis/surgery
Language	English
Publishing date	2023-06-22
Publishing country	Germany
Document type	Journal Article
ZDB-ID	639039-0
ISSN	1432-2218 ; 0930-2794
ISSN (online)	1432-2218
ISSN	0930-2794
DOI	10.1007/s00464-023-10169-9
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Article ; Online: Utilization of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Maneuver for Transcystic Intrahepatic Access.

Nassar, Ahmad H M / Gough, Vivienne / Ng, Hwei J / Katbeh, Tarek / Khan, Khurram

Annals of surgery

2023 Volume 277, Issue 2, Page(s) e376–e383

Abstract: Objective: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy.: ... ...

Abstract	Objective: This study aims to examine the indications, techniques, and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the wiper blade maneuver (WBM) for transcystic intrahepatic choledochoscopy. Summary of background data: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particularly with the increasing role of transcystic exploration. Methods: The indications, techniques, and operative and postoperative data on choledochoscopy collected prospectively during transcystic and choledo- chotomy explorations were analyzed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochoscopes. Results: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during 1320 bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilized more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts, and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. Twenty retained stones (2.1%) were encountered but no choledochoscopy related complications. Conclusions: Choledochoscopy should always be performed during a chol- edochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilized in over 50% of explorations, increasing their rate of success. When attempted, the transcystic WBM achieves intrahepatic access in 70%-80%. It should be part of the training curriculum.
MeSH term(s)	Humans ; Gallstones/surgery ; Laparoscopy/methods ; Common Bile Duct/surgery ; Cholecystectomy, Laparoscopic/methods ; Catheterization
Language	English
Publishing date	2023-01-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000004912
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Article ; Online: Response to the Comment on "Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations".

Nassar, Ahmad H M / Ng, Hwei J / Katbeh, Tarek Z / Cannings, Elizabeth

Annals of surgery

2021 Volume 274, Issue 6, Page(s) e902–e903

MeSH term(s)	Choledocholithiasis/surgery ; Gallstones/surgery ; Humans ; Laparoscopy ; Sphincterotomy, Endoscopic
Language	English
Publishing date	2021-05-24
Publishing country	United States
Document type	Letter ; Comment
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000004945
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Article ; Online: Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations.

Nassar, Ahmad H M / Ng, Hwei J / Katbeh, Tarek / Cannings, Elizabeth

Annals of surgery

2020 Volume 276, Issue 5, Page(s) e493–e501

Abstract: Objective: The primary aim of this study was to describe the service model of one-session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to ... ...

Abstract	Objective: The primary aim of this study was to describe the service model of one-session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE. Background: The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones. Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although LCBDE deals with gallstones and ductal stones in onw session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach. Methods: Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analyzed. Results: One thousand eighteen consecutive LCBDE were included (23% of the series). Intraoperative cholangiography was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity, and 0.2% mortality. Postoperative ERCPs were needed in 3.1%. Recurrent stones occurred in 3%. Conclusions: One stage LCBDE is a safe and cost-effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first-line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimize the outcomes of managing common bile duct stones.
MeSH term(s)	Cholangiopancreatography, Endoscopic Retrograde/methods ; Cholecystectomy, Laparoscopic/methods ; Choledocholithiasis/complications ; Choledocholithiasis/surgery ; Female ; Gallstones/complications ; Gallstones/surgery ; Humans ; Laparoscopy ; Male ; Middle Aged ; Prospective Studies ; Retrospective Studies
Language	English
Publishing date	2020-12-18
Publishing country	United States
Document type	Journal Article
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000004680
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