Prognostic and predictive value of tumoral DNA damage repair protein expression in patients with resected pancreatic cancer

OBJECTIVE

DNA damage repair (DDR) gene mutations gained interest in the treatment of metastatic pancreatic cancer (PC) patients, but their relevance in adjuvant setting is not well characterized. We assessed the prognostic and predictive potential of tumoral expression of DDR proteins along with clinical and tumor characteristics in patients with resected PC.

PATIENTS AND METHODS

Patients with PC who underwent pancreatic resection in our institution between 2005 and 2017 were retrospectively retrieved. Tumoral expression of a panel of DDR proteins including BRCA1, BRCA2, ATM, and p53 with immunohistochemistry was evaluated and association with patient and tumor features as well as prognosis was assessed.

RESULTS

130 patients were included in the study. The median age was 61 and 66% were males, 57% had lymph node involvement and 17% had a vascular invasion. 25 patients (19%) had thrombosis at the time of diagnosis. Median overall survival (OS) and disease-free survival (DFS) were 21.6 and 11.8 months, respectively. More advanced disease stage (HR: 3.67 95% CI 1.48-9.12, p = 0.005), presence of thrombosis (HR: 2.01 95% CI 1.04-3.89, p = 0.039), high BRCA1 expression (HR: 2.25, 95% CI 1.13-5.48, p = 0.023) and high post-operative CA 19-9 level (>100 IU/ml) (HR:2.61 95% CI 1.40-4.89, p = 0.003) were associated with shorter DFS. BRCA2, ATM, and p53 expression were not associated with DFS or OS. Adjuvant gemcitabine-cisplatin regimen was not associated with increased DFS or OS in the whole group, neither in low or high expressors of BRCA1, BRCA2, ATM or p53.

CONCLUSION

Contrary to BRCA2, ATM, and P53, BRCA1 expression may be beneficial for prognosis in resected pancreatic cancer, while no predictive role was observed in terms of adjuvant platinum efficacy.

Human splenic polymorphonuclear myeloid-derived suppressor cells (PMN-MDSC) are strategically located immune regulatory cells in cancer

In contrast to the mouse, functional assets of polymorphonuclear myeloid-derived suppressor cells (PMN-MDSC) in the human spleen remain to be better elucidated. Here, we report that the spleen in gastric and pancreatic cancer adopts an immune regulatory character, harbors excessive amount of PMN-MDSC, and anatomically enables their interaction with T cells. Compared to the peripheral blood, the spleen from cancer patients contained significantly higher levels of low-density PMN-MDSC, but not early-stage MDSC (e-MDSC) and monocytic-MDSC (M-MDSC). Low-density fraction of polymorphonuclear (PMN) cells was enriched in immature myeloid cells and displayed higher levels of CD10, CD16, and ROS than their blood-derived counterparts. They were also positive for PD-L1, LOX-1, and pSTAT3. The white pulp and periarteriolar lymphoid sheath (PALS) were strategically surrounded by PMN cells that were in contact with T cells. Unlike those from the blood, both low-density and normal-density PMN cells from the human spleen suppressed T cell proliferation and IFN-γ production. Independent of clinical grade, high PMN-MDSC percentages were associated with decreased survival in gastric cancer. In summary, our results outline the immune regulatory role of the spleen in cancer where neutrophils acquire MDSC functions and feasibly interact with T cells.

Cyst of the canal of nuck: A rare cause of inguinal swelling in women

Among various reasons of swellings in the female inguinal region nuck canal cysts are rare entities. Abnormal persistence of procesus vaginalis opening cause this formation. Presentation at adults can lead misdiagnosis. Inguinal hernia, tumors (benign or malign), cysts, lymphadenopathies and endometriosis are other common reason for female groin swelling. Once diagnosed surgical excision is definitive treatment.

Analysis of Fusobacterium nucleatum and Streptococcus gallolyticus in saliva of colorectal cancer patients

Aim: The aim of the study was to examine the prevalence and amount of Fusobacterium nucleatum (Fn), Porphyromonas gingivalis (Pg) and Streptococcus gallolyticus (Sg) in the saliva of colorectal cancer (CRC) patients and controls. Methods: PCR analyses performed in 71 CRC patients and 77 controls. Results: Saliva samples of patients had higher amounts of Fn (p = 0.001) and Sg (p < 0.001) compared with controls. Amount of Fn and Sg were lower in the microsatellite instability (+) group. Evaluation of salivary Sg amount by receiver operating characteristics analysis found to have diagnostic value for CRC (AUC: 0.84, 95% CI: 0.72-0.96). Conclusion: We found higher amounts of Fn and Sg in the saliva of CRC patients. Salivary Sg could helpful in distinction of CRC.

Urinary and Fecal Diversion Following Pelvic Exenteration: Comparison of Double-Barrelled and Plain Wet Colostomy

PURPOSE

To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simultaneous fecal and urinary diversion with plain wet colostomy (PWC) or double-barrelled wet colostomy (DBWC).

MATERIALS AND METHODS

The medical records of all patients who had undergone pelvic exenteration and urinary diversion between 2006 and 2017 at our hospital were reviewed retrospectively.

RESULTS

In total, 15 patients with a mean age of 56 ± 13 years were included in the study. Simultaneous urinary and fecal diversions were carried out as PWC (n = 8), or DBWC (n = 7). No significant differences were found between PWC and DBWC groups in terms of operation time (373.7 ± 66.5 versus 394.2 ± 133.2 min, P = .955), estimated blood loss (862.8 ± 462.4 versus 726.2 ± 489.4 mL, P = .613), length of hospital stay (13.2 ± 9.1 versus 14.1 ±6.9 days), early complications (25% versus 28.6%, P = 1.0) and late term complications (37.5% versus 42.9%, P = 1.0). The rate of recurrent pyelonephritis in PWC group was higher than DBWC group but not statistically significant (37.5% versus 14.3%, P = .569). Overall survival (OS) of the patients was 385 ± 91 days. There was no difference between OS of patients with PWC and DBWC (414 ± 165 versus 352 ± 70 days, P = .618).

CONCLUSION

PWC and DBWC are valid options for creating simultaneous urinary and fecal diversion after extensive pelvic surgery in patients with short life expectancy. DBWC might be superior to PWC in terms of decreased risk of recurrent pyelonephritis.

Impact of repeated abdominal surgery on wound healing and myeloid cell dynamics

BACKGROUND

Even though wound dehiscence is a surgical complication, under certain medical conditions, repetition of the laparotomy (LT) (relaparotomy) can become inevitable. In addition to the risks associated with this surgical operation, relaparotomy can interfere with the tissue healing and contribute to the development of chronic wounds.

METHODS

In an experimental relaparotomy wounding model, this study investigated the impact of repeated surgery on wound healing and on the immune cells of myeloid origin.

RESULTS

The first repeat of the LT triggered fibrosis and marginally interfered with the wound healing; however, the second operation completely abrogated the healing process. Splenomegaly was observed as an indicator of the chronic inflammation and the systemic effect of repeated laparotomies. In the blood stream, the spleen, and the liver, these repeated surgeries exhibited a major impact on the CD11b⁺Ly6C⁺Ly6G^- monocytes. On the other hand, especially, whespecially the second relaparotomy resulted in a massive purging of neutrophil granulocytes into the circulation. These CD11b⁺Ly6C⁺Ly6G⁺ neutrophils that were disseminated on repeated abdominal laparotomies had a proinflammatory character that positively influenced T cell proliferation and displayed a high capacity for production of reactive oxygen species.

CONCLUSIONS

The repetition of abdominal LT not only interferes with the wound healing but also contributes to the development of imperfectly healing wounds which have systemic impact on immune compartments.

Hepatoprotective effect of pioglitazone in cases of chemotherapy induced steatohepatitis

BACKGROUND/OBJECTIVES

To evaluate the harmful effects of 5-floururacil (5-FU) and Irinotecan on the liver and to determine the role of Pioglitazone in averting liver damage.

METHODS

Sixty Sprague-Dawley female rats were divided into 4 groups. The first group (n=20) was administered 40 mg of 5-FU and 40 mg kg of Irinotecan intraperitoneally for 4 cycles, while the second group (n=20) received 4 mg kg of Pioglitazone by gastric gavage at 5 days a week for 20 days in addition to chemotherapy. The third group (n=10) was the sham group; chemotherapy regimen was given as in the first group. In addition, normal saline was given daily for 20 days by gastric gavage. The fourth group (n=10) was only given a standard diet as a control group. Then, blood samples were studied for the evaluation of alanine aminotransferase (AST)and alanine aminotransferase (ALT) levels. And left liver lobes of rats were taken for pathological analysis.

RESULTS

Although short-term chemotherapy was administered,aminotransferase (AST) and alanine aminotransferase (ALT)levels were found to be significantly higher in the first and third groups compared to the others (p 0.0001). No significant difference was determined between the second and the control group. Pioglitazone reduced the adverse metabolic effects of chemotherapy on the liver, but had no effect on the histopathological changes.

CONCLUSION

short-term CT causes metabolic disruption in hepatocytes, but not relevant with CASH. Preventive treatments like Pioglitazone should be used more carefully.

Is surgical treatment of liver hemangiomas effective for pain relief?

BACKGROUND

Traditional treatment for liver hemangiomas is surgery. Currently, it is controversial whether hemangioma surgeries are sufficiently beneficial for the patients. In this study, we evaluated the effectiveness of surgery in patients with liver hemangiomas.

METHODS

Forty-two patients who underwent surgical operations for hepatic hemangiomas were retrospectively evaluated and interviewed.

RESULTS

Study population included 36 female and 6 male patients whose ages ranged between 26 and 65 years (mean age, 47.8 +-8.7 years). Their mean duration of hospitalization was 6 days (range, 3 - 59 days). The median time since surgery was 50 months (range 0-120 months). There was a statistically significant decrease in numerical rating and adjective rating pain scale scores (p 0.05). Postoperatively, pain did not cease in 10 patients (peptic ulcers requiring medical treatment in four patients, cholelithiasis in four patients, and nephrolithiasis in two patients).

CONCLUSION

Patients with cavernous hemangiomas of the liver who require surgical treatment have significant benefits in terms of pain relief following surgery. The lack of pain relief after the surgery in some patients may be related to concomitant medical problems other than the hemangioma.

The impact of adjuvant delayed radiotheraphy (RT) on survival in patients with resected periampullary adenocarcinomas

e15168

Background: Postoperative prognosis for ampullary carcinoma (AC) is superior to that of pancreatic cancer (PC), the former exhibiting higher complete surgical resection, lower recurrence and longer survival rates (1). Despite all the major recent advances in surgery, chemotherapy (CT) and RT, PC is still one of the most lethal malignancies, overall survival (OS) rates being as low as 5% at 5 years (2). This study was intended to evaluate survival in patients with resected periampullary cancer treated with adjuvant Gemcitabine (Gem) and cisplatin (Cis) with or without delayed RT (with Gem). Methods: This retrospective study involved 91 patients diagnosed and treated with periampullary cancer. Patients with adenocarcinoma of periampullary region with gross total tumor resection and lymph node dissection (R0 and R1 resections only) were included. Of 59 patients with PC, 38 received Gem and Cis for 3 cycles (3 months) before CRT. When delivered after Gem /RT, Gem and Cis were usually given for another 1-3 cycles. Twenty-seven patients received Gem and Cis alone over 6 cycles. Of 32 patients with non-pancreatic periampullary 23 received CT+CRT and 9 patients received CT alone. Results: Patients with non-pancreatic periampullary cancer had better OS (p:0.017) and disease free survival (DFS) ( p<0.001 ) compared to patients with PC. Median OS of patients with PC was 21 months. Both OS and DFS were superior in the RT arm compared to nonRT arm (p: 0.043 and p <0.001). In non-pancreatic periampullary cancer patients OS was 31 months in RT group and 51 months in non-RT group (p: 0.709). DFS was 29 months and 49.8 months respectively, p:0.504). Conclusions: The prognosis of PC was worse than non–pancreatic periampullary tumor. In PC adjuvant delayed RT improved patient outcome. Although OS and DFS were better in patients receiving CT alone, the difference was not statistically significant in non–pancreatic periampullary tumors.

A case of recurrent metastatic hepatocellular cancer controlled with immunotherapy and antiviral therapy following resection

Hepatocellular carcinoma (HCC) is the most frequent malignant tumour of the liver. The risk of HCC in chronically hepatitis B virus (HBV) infected individuals is approximately 100-fold higher than in the uninfected population. Despite all therapeutic advances, the benefit of systemic chemotherapy in patients with HCC has limited. But, the phase III clinical trial conducted in patients with advanced HCC treated with sorafenib has showed significant improvements in both overall and progression-free survival Metastasis from liver to extrahepatic tissues is reported to be quite uncommon and has a poor prognosis. Here we present a case of HCC which metastasized to the vertebrae, lung and kidney in order of appearance and controlled with immunotherapy and antiviral therapy following resection.

Determinants of postoperative infection after laparoscopic cholecystectomy

BACKGROUND/AIMS

The aim of this study was to evaluate the effect of antibiotic prophylaxis on the development of infectious complications in laparoscopic cholecystectomy.

METHODOLOGY

A total of 208 patients undergoing elective laparoscopic cholecystectomy were randomized, double-blinded into one of two treatment arms: 1) cefazolin 1 g intravenously after induction of anesthesia and 2) no prophylactic antibiotics. The patients were followed-up for infectious complications for 30 days at the out-patient clinic. The data collected included age, sex, body mass index, ultrasonography findings, accompanying diseases, perforation during surgery, stone spillage, operation time, port of gallbladder delivery, suture material used for skin closure, preoperative and length of postoperative hospitalization, bile culture, pathology of the gallbladder, serum biochemical findings including alanine aminotransferase, aspartate aminotransferase, gammaglutamyl transpeptidase, bilirubin, alkaline phosphatase and glucose.

RESULTS

Overall rate of infection was 3.36%. Four out of 105 patients who received antibiotics and 3 out of 103 patients who did not receive antibiotics developed infection. The difference was not statistically significant. Obesity and closing the skin with nylon sutures were found to be associated with increased rate of infectious complications.

CONCLUSIONS

Cefazolin prophylaxis in low risk patients has no effect on postoperative infection rate in laparoscopic cholecystectomy.

Pancreaticojejunostomy after pancreaticoduodenectomy: results of a new technique

BACKGROUND/AIMS

Pancreaticoduodenectomy is the standard treatment for periampullary tumors. One of the major causes of morbidity after pancreaticoduodenectomy is the failure of the healing at the pancreaticoenteric anastomosis. The aim of this study is to summarize the results of a new technique which is designed to decrease the panreticoje-junostomy anastomotic leakage.

METHODOLOGY

The demographic characteristics, operation indications, types of the pancreaticoduodenectomy, duration of the postoperative hospitalization, morbidity and mortality of the consecutive patients whose pancreaticojejunostomy anastomosis after pancreaticoduodenectomy was performed by modified invagination method at Hacettepe University Medical School Department of General Surgery between February 2005 and December 2007 were evaluated prospectively.

RESULTS

Thirtyone patients were included in the study. The operation indications were pancreas cancer for 17 patients, ampulla Vateri cancer for 8 patients, duodenum cancer for 3 patients, cancer of the distal choleduct for 2 patients and gall bladder cancer for 1 patient. Twenty complications had occurred in a total of 15 patients. There were no pancreaticojejunostomy anastomotic leakage and mortality in any of the patients.

CONCLUSIONS

An ideal pancreaticojejunostomy anastomosis after pancreaticoduodenectomy should be safe, simple and secure. This modified invagination method seems to be promising when these parameters are taken in to account.

Controversies in periampullary tumors

Periampullary tumors are one of the most common tumors of the gastrointestinal tract. Despite the increase of 1-5% in five year life expectancy in periampullary tumors prognosis is still poor. The controversies in diagnosis, surgical and adjuvant treatment will be discussed in this article.

Hepatic focal nodular hyperplasia developing in a Fanconi anemia patient: a case report and literature review

Fanconi anemia, an autosomal recessive and X-linked disorder, is known to be associated with a variety of neoplasms. Liver tumors are one of the most frequently observed neoplasms but the association between the two disorders remains obscure. We present a case of a 27-year old female Fanconi anemia patient diagnosed with a mass on the right lobe of the liver measuring 90x75x60 mm. Histopathological examination of the mass after right hepatic lobectomy revealed focal nodular hyperplasia. This appears to be the first reported case of a hepatic focal nodular hyperplasia of such proportion associated with Fanconi anemia. Previously reported cases of liver tumors in association with Fanconi anemia in the English Literature were either hepatocellular carcinomas or hepatic adenomas.

Synchronous and metachronous occurrence of gastric adenocarcinoma and gastric lymphoma: A review of the literature

The occurrence of both primary gastric lymphoma and gastric adenocarcinoma in the same patient is a rare entity. The possible causative factors of synchronous or metachronous occurrence of both malignancies and varieties in the treatment modalities are reviewed according to published cases in English language medical literature.

In vivo characterisation of parathyroid lesions by use of gamma probe: comparison with ex vivo count method and frozen section results

OBJECTIVE

In this study we hypothesized that if timing of gamma probe-guided parathyroidectomy were individualized according to an optimal-time-to-surgery technique, in vivo characterization of parathyroid lesions would be possible. We compared our findings with an ex vivo counting method ("20% rule") and frozen section results.

STUDY DESIGN AND SETTINGS

Thirty-five patients who were referred for surgical treatment of hyperparathyroidism were studied. Maximum parathyroid to thyroid sestamibi uptake ratio (UR(max)) was measured by use of preoperative dynamic scintigraphy. The interval between sestamibi injection and UR(max) was defined as the optimal time to surgery. On the day of surgery, the patients received the same dose of sestamibi and were taken to the operating room at UR(max) as determined by preoperative scintigraphy. Intraoperative in vivo gamma probe counts from parathyroid lesions were compared with in vivo contralateral background thyroid counts (in vivo/Bkg) and to ex vivo parathyroid counts relative to postexcision background of the adjacent normal tissue (ex vivo/Bkg).

RESULTS

A total of 70 excised lesions were evaluated. In vivo/Bkg counts obtained from parathyroid adenoma were significantly different from parathyroid hyperplasia (z = -3.093, P = 0.002) and other lesions (z = -3.958, P = 0.0001). By receiver operating characteristic curve (ROC) analysis, we found the cutoff value for the in vivo/Bkg counts ratio to be 103% to differentiate parathyroid adenoma from hyperplasia with a sensitivity, specificity, and accuracy of 82.5, 65, and 74.4%, respectively. On the other hand, sensitivity, specificity, and accuracy of the ex vivo/Bkg method to differentiate parathyroid adenoma from hyperplasia with a cutoff value of 34.7 was found to be 70.8%, 60%, and 65.9%, respectively. The difference between the accuracy of these 2 tests was not significant statistically (P = 0.137). Sensitivity of frozen section to differentiate parathyroid adenoma and hyperplasia was 76.2% and 33.3%, respectively.

CONCLUSIONS

Patient-specific optimal protocol for timing of sestamibi injection together with in vivo/Bkg method is a useful alternative method in guiding the surgeon to differentiate parathyroid adenoma from parathyroid hyperplasia and other tissues and may help surgeons' decisions during the operation. Combined use of in vivo/Bkg and ex vivo/Bkg methods may give more accurate results than frozen section.

Giant liver hemangioma: therapy by enucleation or liver resection

Hemangioma is the most common primary tumor of the liver. The widespread use of ultrasonography (USG) and computed tomography (CT) has made the diagnosis more common. Although the vast majority of hemangiomas are diagnosed incidentally and are asymptomatic, treatment is still controversial. Surgery is the treatment of choice, especially in giant, symptomatic hemangiomas and uncertainty of diagnosis. Twenty-two patients (median age: 46 years) underwent resection (n = 12) or enucleation (n = 10) for liver hemangioma from 1989 to 2002. The primary indication for surgery was abdominal pain. Ten patients who were treated by enucleation were compared with twelve patients who were treated by liver resection. Mean tumor size was 90 mm with a range of 40-270 mm. There were no statistically significant differences in tumor size, preoperative liver function tests, hemoglobin levels, and platelet counts between the two groups. Operative time was longer in the resection group, and statistically significant the difference was (p = 0.048). Blood transfusion requirement and blood loss during intraoperative period were higher in the resection group (p = 0.025, p = 0.01, respectively). There were three postoperative complications, 1 in the enucleation group (pleural effusion), 2 in the resection group (liver abscess and wound infection). There was no surgery-related mortality in either group. Although most hemangiomas can be removed by enucleation or liver resection with low morbidity and mortality, if the location and number of hemangiomas are appropriate, enucleation is the choice of the therapy. Hospital stay, blood transfusion requirement, and blood loss can be kept minimal by the selection of enucleation.

A case of acute pancreatitis in a patient with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an auto-immune disease which can affect multiple organs. It may also involve the pancreas and in rare cases may cause acute pancreatitis. The etiology of acute pancreatitis in SLE is a matter of controversy. We present a case diagnosed with SLE that developed acute pancreatitis while being treated with corticosteroids. During the course of the disease, pancreatic pseudocysts developed and were treated by percutaneous drainage. There are few reports in the literature about the therapy of acute pancreatitis and percutaneous drainage of pseudocysts in SLE. We discuss the pathogenesis and therapy for acute pancreatitis in SLE patients.

Effects of low and high intra-abdominal pressure on immune response in laparoscopic cholecystectomy

OBJECTIVE

Immunosuppression is directly related to the degree of trauma. The aim of this study is to compare the effects of low and high intra-abdominal pressure on immune response in moderate surgical trauma.

METHODS

Twenty-two patients, scheduled for laparoscopic cholecystectomy, were randomly allocated to one of 2 groups according to intra-abdominal pressure: low and high intra-abdominal pressure. This study was conducted in the Hacettepe University Faculty of Medicine, Operation Room, Ankara, Turkey. Serum interleukin (IL)-2 and IL-6 levels were measured.

RESULTS

Serum IL-2 showed a significant decrease before the incision in high intra-abdominal pressure group. The increase in serum IL-6 at the end of surgery and postoperatively was lower in low intra-abdominal pressure group.

CONCLUSION

These results, can be interpreted as the immune system, are less depressed when there is lower intra-abdominal pressure. This may have clinical implications in immunocompromised patients.

Clinicopathologic and Radiopharmacokinetic Factors Affecting Gamma Probe–Guided Parathyroidectomy

HYPOTHESIS

The kinetics of technetium Tc 99m sestamibi (MIBI) in primary hyperparathyroidism are variable and affected by the cellular size of the abnormal glands, the parathyroid hormone levels, and the functional expression of P-glycoprotein (Pgp). The success of gamma probe-guided parathyroidectomy is closely related to the parathyroid-to-thyroid activity ratio at the time of surgery. Preoperative determination of maximum uptake ratio may improve the surgical outcome.

DESIGN

Thirty-one patients with primary hyperparathyroidism attributed to a solitary parathyroid adenoma (27 patients) or multiglandular hyperplasia (4 patients) underwent dynamic MIBI imaging preoperatively. Maximum MIBI activity and activity elimination half-life in the abnormal parathyroid glands and thyroid glands were measured, and the maximum uptake ratio was calculated. After a second MIBI injection on the day of surgery, all patients underwent gamma probe-guided parathyroidectomy and cervical exploration. Timing of surgery after MIBI injection was individualized according to the optimal time to surgery (time to maximum uptake ratio), which was determined by preoperative scintigraphy. During surgery, the gamma probe was used to measure ex vivo counts of excised lesions and adjacent postexcision normal tissue (background). Image characteristics, MIBI kinetics, and gamma probe findings were correlated with gland volume, oxyphil cell content, Pgp expression, and serum parathyroid hormone levels.

RESULTS

Probe localization of abnormal glands at maximum uptake ratio was successful in all patients. The volume of the parathyroid lesion ranged from 0.03 to 9.8 mL (median, 0.7 mL). Parathyroid maximum MIBI activity correlated with the volume of the gland (r = 0.54, P = .002) and serum parathyroid hormone level (r = 0.58, P = .001). No correlation between maximum MIBI activity and oxyphil cell content or Pgp expression could be demonstrated. Elimination half-life of MIBI from parathyroid inversely correlated with Pgp (r = -0.36, P = .05). The ex vivo lesion-background count ratio positively correlated with volume of the gland (r = 0.66, P = .001) and parathyroid hormone level (r = 0.48, P = .006). Ex vivo lesion counts and Pgp expression were negatively correlated (r = -0.37, P = .04).

CONCLUSIONS

A strong relationship between volume of the parathyroid gland, serum parathyroid hormone levels, and MIBI uptake exists in primary hyperparathyroidism. Gamma probe-guided localization of abnormal gland(s) can be more successful if surgery is undertaken at maximum uptake ratio. High Pgp expression increases MIBI parathyroid clearance rate, decreases gamma probe counts, and may significantly alter the optimal time to surgery.

Laparoscopic splenectomy for haematological diseases

PURPOSE

To show the utility of laparoscopic splenectomy for hematologic diseases.

PATIENTS AND METHODS

Ten patients with hematologic diseases who were operated between February 1997 and October 1998 were analysed retrospectively.

TECHNIQUE

The operations were performed by four trocars, hilar vessels were divided by clips and bag was used for splenic retrival.

RESULTS

All operations were completed successfully. No accessory spleens were found. Intraoperative complication, other than a bag tear in one operation did not occur. Postoperative complications occurred in two patients. The first one was a portal vein thrombosis and the second one was a peritonitis. All patients responded hematologically to the operation.

CONCLUSION

With appropriate surgical technique and patient follow up, laparoscopic splenectomy is a safe, adventageous and efficaceus operation for hematologic diseases.

Hyperfunctioning parathyroid cysts: a case report

Parathyroid cysts are infrequent lesions of which most are non-functional. They are often misdiagnosed as thyroid cysts. Pre-operative diagnosis and differentiation from thyroid cysts is generally difficult. We hereby report a case that was admitted to the emergency room and was diagnosed as hypercalcemic crisis. The mass found during the neck examination was thought to be a thyroid nodule. A right total and left subtotal thyroidectomy was performed. Palpable thyroid nodule was diagnosed as cystic parathyroid adenoma postoperatively. When a cystic lesion is found in the neck of a patient, a pararthyroid cyst should be considered.

Optimization of the Gamma Probe-Guided Parathyroidectomy

The objective of this study was to determine the patient-specific optimal time to surgery preoperatively to improve operative success in gamma probe-guided parathyroid localization. Fifteen patients with hyperparathyroidism underwent a double-phase Tc99m-MIBI (15–20 mCi) parathyroid scintigraphy to study the Tc99m-MIBI clearance kinetics from parathyroid and thyroid glands and to determine the time point at which the optimal target-to-background ratio was achieved. Optimal time to surgery was determined on the basis of the time at which the target-to-background ratio was maximal. On the day of surgery the patients received the same dose of Tc99m-MIBI and were taken to the operating room at the time of optimal target-to-background ratio. A four-gland exploration was performed with identification and excision of hot lesions using a gamma probe. Ex vivo lesion-to-background ratios were determined. Histopathologic confirmation of a successful parathyroidectomy was obtained intraoperatively by frozen section. The total operative time and the time to localize and excise the parathyroid glands were recorded. The mean surgery time was compared with that of previous parathyroidectomies performed by the same surgical team without use of preoperative scintigraphy and intraoperative gamma probe. Scintigraphy correctly localized parathyroid pathology in 12 of 15 (80%) patients. Intraoperative gamma probe was successful in 15 of 15 (100%). The optimal time to surgery was found to be different for each patient, and the mean time was calculated as 136 ± 43 minutes. Mean surgery time for the excision of parathyroid gland was 91 ± 46 minutes, which was significantly shorter than previous four-gland exploration without use of scintigraphy and gamma probe (160 ± 61 minutes; t = 3.021, P = 0.007). The mean ex vivo lesion-to-background gamma probe count ratio of abnormal parathyroid glands (77.35) was found to be significantly higher than that of all other lesions with abnormal Tc99m-MIBI uptake (5.05) ( U = 10.5, P < 0.0001). Optimal target-to-background ratio is essential for the success of gamma probe-guided parathyroidectomy. This ratio was highly variable among the patients in this study. Individualization of the best surgical exploration time after Tc99m-MIBI injection will improve the surgical success of this operation.

The abdominal cocoon: a case report

The abdominal cocoon is a rare disease that is characterized by a total or partial encasement of the small bowel by a thick and fibrotic membrane. Thirty-five cases were reported since it was first described. It occurs primarily in females. Preoperative diagnosis is a matter of challenge and usually made at laparotomy. We report a patient with partial intestinal obstruction and abdominal cocoon which was diagnosed peri-operatively. We review the literature and discuss the etiology of this disease.

Diaphragmatic herniation after transhiatal esophagectomy

Increasing experience with transhiatal esophagectomy (THE) has brought with it a good understanding of the advantages and disadvantages of the technique. As in our case, diaphragmatic hernias after THE may result from excess manipulation and extension of the hiatus during surgery. The varying nature of the clinical presentation may cause delay in diagnosis. We report our case and discuss how to diagnose and manage this complication under the sum of cases reported previously in English literature.

Portomesenteric gas due to intestinal obstruction: a case report

A case of mesenteric vein gas as a nonfatal complication of intestinal obstruction is reported. A 48-year-old woman presented postoperatively signs and symptoms of acute abdomen on the eighth day following a gastric pull-up surgery due to an oesophageal carcinoma. The abdominal tomography findings revealed dilated jejunal segments and free gas in the superior mesenteric vein and end branches of the portal vein in the left hepatic lobe. The patient underwent a second laparotomy with a provisional diagnosis of intestinal ischaemia. Intraoperative gross appearance of the intestines revealed no ischaemic finding, the pathology was the dense adhesions between the jejunal segments and previous incision site. On the basis of these findings, the operation was ended with adhesiolysis. One month after the operation, the patient was well, there were no complications. As the authors, we think that the main reason for portomesenteric gas is mucosal destruction and that these case may be followed conservatively as long as intestinal ischaemia is excluded.

Antegrade jejunojejunal intussusception after Roux-en-Y esophagojejunostomy as an unusual cause of postoperative intestinal obstruction: report of a case

Postoperative intestinal obstruction in adults is rarely caused by intussusception. A case of antegrade jejunojejunal intussusception that occurred after Roux-en-Y esophagojejunostomy is described, followed by a discussion of the literature on this unusual entity.

Hydatid cyst of the spleen: treatment options

Hydatidosis is a highly endemic parasitic disease caused by Echinococcus. The spleen is infrequently involved in hydatid disease. Splenectomy is the conventional treatment, but there are other treatment options as well. In this article, we reviewed the data of 14 patients with splenic hydatidosis operated on during the last 20 years. The spleen was involved in 2.5% of all abdominal hydatidosis cases during this period and was the only location of disease in 7 of the 14 patients. Partial cystectomy and omentopexy was performed on 2 patients, and splenectomy was performed on 12 patients. In 2 patients, percutaneous drainage was the initial choice of treatment but was not successful, and splenectomy was performed eventually. There was no mortality, and the morbidity rate was 28.6%. Although currently splenectomy is the conventional treatment, experience suggests that partial cystectomy and omentopexy should be the procedure of choice for the treatment of splenic hydatidosis.

Traumatic diaphragmatic hernias: a report of 26 cases

Traumatic diaphragmatic hernias, when diagnosed many years after the traumatic event, are observed in about 10% of diaphragmatic injuries. Due to coexisting injuries and the silent nature of diaphragmatic injuries, the diagnosis is easily missed or difficult. The medical records of 26 patients, who were treated for diaphragmatic hernias during the last 20 years, were analysed retrospectively. The patients were divided into acute phase and late-presenting groups, in whom emergency surgery and elective intervention were performed respectively. Chest radiography was diagnostic in 34.6% (n = 9) of patients. 92.3% of the hernias were on the left side, while the most common herniated organs were the stomach (31.8%) and the colon (27.2%). Coexisting injuries were recorded in 38.4% (n = 10) of the patients. Primary repair was predominantly used (92.3%). The hospitalisation period was longer in the late-presenting group (24.1 +/- 18.8 vs. 14.3 +/- 7.7 days). Two deaths occurred in the late-presenting group. Diaphragmatic hernia should be suspected in all blunt abdominal trauma patients. Prompt surgical repair is the treatment of choice in all traumatic diaphragmatic hernias.

Effects of CO2 insufflation and laparotomy on wound healing in mice

BACKGROUND

The aim of the present study was to evaluate the effects of laparotomy and CO2 insufflation on wound healing in a murine incisional wound healing model.

METHODS

Seventy-two male Swiss Albino mice were randomly allocated into three groups of control, laparotomy and CO2 insufflation. A transverse skin incision of 15 mm was made in the dorsum of each mouse, and four interrupted mattress sutures with 4.0 polypropylene thread were laid for wound closure. A median laparotomy was performed in the laparotomy group. CO2 insufflation was performed with an intra-abdominal pressure of 9 mmHg. The retained gas was evacuated from the abdominal cavity at the end of a 60-min period. Mice were killed on the 3rd, 7th and 15th postoperative days. The wound tensile strength and 5-hydroxyproline concentration in the wound tissue were measured.

RESULTS

Tensile strength of the incised skin increased as the post-incision period progressed. There was no significant difference between the tensile strengths of the incised skin of control, laparotomy and CO2 insufflation groups throughout the observation period. The skin 5-hydroxyproline concentrations of all groups were not significantly different at the 3rd postoperative day. But laparotomy and CO2 insufflation groups had lower 5-hydroxyproline concentrations at the 7th and 15th postoperative days, when compared to controls (P < 0.02 for 7th and 15th days).

CONCLUSION

CO2 insufflation and laparotomy reduce the 5-hydroxyproline concentration of the wound, suggesting a diminished wound healing capacity.

Perforation of acute calculous Meckel's diverticulitis: a rare cause of acute abdomen in elderly

Complications of the Meckel's diverticula are well-known and defined. However, acute inflammation and perforation secondary to a calculus is a rare clinical presentation. A case of acute calculous Meckel's diverticulitis with perforation in a 58-year old man is presented and possible pathological conditions are discussed. Location of the perforation, apical microscopic focal ulcers, and ischaemic changes in the diverticulum remind the pathogenesis comparable to that of acute calculous cholecystitis. This case report with major complications related to Meckel's diverticulum strengthens the concept of prophylactic resection of Meckel's diverticulum in adults, incidentally discovered at laparotomy.

Melatonin modulates mesenteric blood flow and TNFalpha concentrations after lipopolysaccharide challenge

OBJECTIVE

To investigate the effect of various doses of melatonin on reduction in mesenteric blood flow (MBF) and increase in tumour necrosis factor alpha (TNFalpha) concentration caused by injection of lipopolysaccharide (LPS).

DESIGN

University Hospital, Turkey.

SETTING

Open experimental study.

ANIMALS

59 Swiss albino mice.

INTERVENTIONS

Animals were injected with melatonin solvent or 1, 10, 100, or 500 mg/kg melatonin. Ten minutes later control animals were injected with saline, and the experimental group with LPS.

MAIN OUTCOME MEASURES

Mesenteric blood flow and serum TNFalpha concentration.

RESULTS

In control animals, 100 and 500 mg/kg melatonin reduced MBF. LPS reduced MBF in solvent, 1, and 10 mg/kg melatonin groups. The concentration of TNFalpha was considerably increased in the mice given LPS. Melatonin reduced this response significantly.

CONCLUSION

In high doses melatonin directly reduces MBF. It has no protective effect on the LPS-induced decrease in MBF. In lower doses it blocks, but at higher doses reduces, LPS-induced TNFalpha production.

Surgical treatment of substernal goiter

BACKGROUND

Substernal goiter differs from its cervical counterpart in regard to its clinical presentation, surgical management, pathological analysis and postoperative complication.

METHODS

Retrospective analysis of 1320 thyroidectomies performed at the Hacettepe University Hospital between 1990 and 1997.

RESULTS

30 (2.3%) of 1320 thyroidectomies underwent operation for removal of substernal goiters in an 8-year period. The most common symptom was cervical mass (67%) and 33% of the patients were asymptomatic. Computerised tomography was the most accurate pre-operative test for detecting substernal extension. Substernal goiters were removed by collar incisions in 93% of the cases. The pathology was generally found to be benign (94%), but follicular carcinoma was present in two (6%) patients. There was no mortality and no complications were observed in 73% of the patients.

CONCLUSIONS

The presence of substernal goiter is an indication for removal given the lack of any effective medical therapy, low surgical morbidity, risk of malignancy and acute obstructing symptoms.

An experimental study of the adhesive potential of different meshes

OBJECTIVE

To assess the adhesive potential and incidence of incisional hernia with three meshes.

DESIGN

Open experimental study.

SETTING

Surgical Research Laboratory, Turkey.

ANIMALS

75 Wistar albino rats

INTERVENTIONS

Abdominal walls were excised, and defects closed primarily or with polyglactin 910, polypropylene, or dura mater. Adhesions were graded and hydroxyproline concentrations measured on days 14 and 180. On day 180, the incidence of incisional hernia, and the grades of inflammation and fibrosis were also recorded.

RESULTS

The polyglactin 910 group had a higher adhesion grading than the control and dura mater groups on day 14, whereas the polypropylene group had higher adhesion grading than controls. Both polypropylene and polyglactin 910 groups had significantly higher concentration of hydroxyproline than the control and dura mater groups. On day 180, the polypropylene group had a higher adhesion grading than the controls. There were no differences in hydroxyproline concentrations, incidence of hernias, or grading of fibrosis levels among the groups.

CONCLUSION

Polyglactin 910 induced more fibrotic adhesions in the early postoperative period whereas polypropylene did in both the early and late postoperative periods.

Missed malignancies during laparoscopic cholecystectomy

BACKGROUND/AIMS

Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstone diseases. However, besides its great benefits, perhaps the most disappointing complication of this operation is missed malignancies. In this study, patients who had missed malignancies that were diagnosed shortly after laparoscopic cholecystectomy were studied. We aim to find out the cause of missed and delayed diagnosis.

METHODOLOGY

Between 1991 and June 1997, 9 patients undergoing laparoscopic cholecystectomy, which had been performed elsewhere 2-9 months earlier, and having had missed malignancy were included in this study. A diagnostic survey was collected from the medical records, questionnaires, and a semiological analysis. All laboratory data and physical findings, before and after laparoscopic cholecystectomy, were recorded. Follow-up data were obtained through a telephone questionnaire.

RESULTS

Of these 9 patients, 6 had colorectal carcinoma and 3 had pancreas carcinoma. All patients complained of recent atypical pain at the time of laparoscopic cholecystectomy, except for 1 patient who had no symptomatic regression.

CONCLUSIONS

It is necessary to make a careful semiological, physical and laboratory analysis of patients with cholelithiasis before especially laparoscopic cholecystectomy. Elderly patients, atypical biliary pain and associated symptoms must draw attention to the possibility malignancy.

The effects of G-CSF treatment and starvation on bacterial translocation in hemorrhagic shock

BACKGROUND

Bacterial translocation is thought to be responsible for infectious complications after hemorrhagic shock. The aim of this study is to investigate the effects of granulocyte colony-stimulating factor (G-CSF) treatment on bacterial translocation in starved or fed animals subjected to hemorrhagic shock.

MATERIALS AND METHODS

Fifty Wistar albino rats (200-275 g) were divided into six groups such as naive control (n = 7), G-CSF treatment (n = 7), hemorrhagic shock in starved rats (n = 9), hemorrhagic shock in fed rats (n = 9), G-CSF treatment 24 h before hemorrhagic shock in starved rats (n = 9), and G-CSF treatment 20 min after hemorrhagic shock in fed rats (n = 9). Hemorrhagic shock was induced by withdrawal of 2.1 ml/100 g blood via a carotid arterial cannulae placed under sodium pentobarbital anesthesia. Twenty-four hours later, mesenteric lymph nodes, liver, spleen, and peripheral blood samples were evaluated by using a quantitative microbiological technique and the numbers of colony-forming units were compared between groups.

RESULTS

No bacteria was detected in samples from naive controls or G-CSF-treated unshocked rats. In animals subjected to hemorrhage, Escherichia coli was the predominant pathogen together with Streptococcus faecalis, Pseudomonas, and Lactobacillus species. In this model, starvation augmented the magnitude of bacterial translocation while G-CSF treatment has virtually abolished it.

CONCLUSION

Under experimental conditions, preshock starvation increases gut-derived bacterial translocation and administration of G-CSF before or after hemorrhagic insult significantly reduces it.