Is Pain Perception Communicated through Mothers? Maternal Pain Catastrophizing Scores Are Associated with Children's Postoperative Circumcision Pain

The aim of this study was to evaluate the relation of maternal pain catastrophizing score with children who underwent circumcision postoperative pain. This prospective cohort study was performed between March 2022 and March 2023 at Samsun University, Turkey. Demographic characteristics of mothers and children, mothers' education level, presence of chronic pain, and Beck Depression Inventory scores were recorded preoperatively. Pain catastrophizing was assessed by applying the pain catastrophizing scale (PCS) to the mothers of children who experienced postoperative circumcision pain. The mothers were divided into low-pain catastrophizing (Group 1) and high-pain catastrophizing (Group 2) group. A total of 197 mothers and sons participated in the study, with 86 (43.6%) in Group 1 and 111 (56.4%) in Group 2. Significant differences were found between the two groups in terms of the mothers' PCS scores (p < 0.001), education levels (p = 0.004), chronic pain scores (p = 0.022), and Beck Depression Inventory scores (p < 0.001). Our findings showed that children with high pain catastrophizing mothers experience greater postoperative pain than those with low pain catastrophizing mothers. This may be attributable to a mother's specific cognitive style for coping with pain, which is associated with the child's responses to painful experiences.

The Efficacy of Hemoglobin, Albumin, Lymphocytes, and Platelets as a Prognostic Marker for Survival in Octogenarians and Nonagenarians Undergoing Colorectal Cancer Surgery

Objectives: With the aging population worldwide, the octogenarians are becoming a substantial group and since cancer incidence increases by age, this group of patients is becoming more affected. However, no distinct treatment algorithm has been established for elderly patients with cancer. The present study aimed to determine the prognostic value of several inflammatory parameters by comparing octogenarian patients treated surgically for colorectal cancer with their younger counterparts, as well as to predict and prevent age-related complications in this frail group of patients. Methods: The demographic and clinical data were collected from octogenarians and older people as case group (51 patients) and from a nonelderly control group of patients 65 years old or younger (88 patients). Results: The results showed that Hemoglobin, Albumin, Lymphocytes, and Platelets (HALP) values were statistically different between case and control groups. Based on the results of the receiver operating characteristic analysis performed, there was a positive correlation between HALP and survival. HALP had a significant discrimination power at the good level [AUC = 0.775 (0.696-0.854); p < 0.001]. The multivariate model showed that age groups and HALP scores were significant factors for patient survival. Conclusions: HALP biomarker was associated with the prognosis of patients treated surgically for colorectal cancer with curative intent. Furthermore, HALP score was significantly different in octogenarians compared to their younger counterparts. The newly formulated Hemoglobin, Albumin, Lymphocytes, Platelets, and Age (HALPA) appeared to be a promising biomarker of survival for elderly patients scheduled for colorectal cancer surgery.

Is Polycystic Ovary Syndrome a Predisposing Factor for Pilonidal Sinus Disease?

BACKGROUND

The incidence of pilonidal sinus may be increased in women with polycystic ovary syndrome.

OBJECTIVE

This study aimed to compare the prevalence and risk factors of pilonidal sinus disease in women with and without polycystic ovary syndrome in the same population.

DESIGN

This was a case-control study.

SETTINGS

This study was conducted in a Turkish rural district state hospital.

PATIENTS

This study included 40 female patients with polycystic ovary syndrome and 120 female patients without polycystic ovary syndrome.

MAIN OUTCOME MEASURES

The prevalence of pilonidal sinus, age, BMI, number of baths per week, daily sitting time, and family history of pilonidal sinus were recorded.

RESULTS

Pilonidal sinus was detected in 22.5% (12.5% asymptomatic pits, 10% symptomatic) of patients with polycystic ovary syndrome and 1.7% of the control group ( p < 0.001). No difference was noted between the 2 groups in terms of BMI ( p = 0.219). Family history was similar between the case and control groups ( p = 0.520). No significant difference was noted between the 2 groups in terms of insufficient hygiene and daily sitting time ( p = 0.763, p = 0.706). Multivariate analysis showed that the risk of pilonidal sinus was significantly higher in patients with a positive family history ( p = 0.008).

LIMITATIONS

The number of patients in the case and control groups in the study was limited. In addition, the control group may not fully reflect the general population because it was composed of only patients who presented to the general surgery and gynecology outpatient clinic for other reasons. The control group was not age matched.

CONCLUSIONS

In our study, we found that the prevalence of pilonidal sinus was significantly higher in patients with polycystic ovary syndrome. See Video Abstract at http://links.lww.com/DCR/B945 .

ES EL SNDROME DE OVARIO POLIQUSTICO UN FACTOR PREDISPONENTE PARA LA ENFERMEDAD DEL SENO PILONIDAL

ANTECEDENTES:La incidencia de enfermedad del seno pilonidal puede aumentar en mujeres con síndrome de ovario poliquístico.OBJETIVO:El objetivo fue comparar la prevalencia y los factores de riesgo de la enfermedad del seno pilonidal en una misma poblacion de mujeres con y sin síndrome de ovario poliquístico.DISEÑO:Este fue un estudio de casos y controles.ENTORNO CLÍNICO:Se llevó a cabo en un hospital estatal de un distrito rural turco.PACIENTES:Este estudio incluyó a 40 pacientes mujeres con síndrome de ovario poliquístico y 120 pacientes mujeres sin síndrome de ovario poliquístico.PRINCIPALES MEDIDAS DE VALORACIÓN:Se registraron la prevalencia del seno pilonidal, la edad, el IMC, el número de duchas por semana, el tiempo diario para sentarse y los antecedentes familiares de seno pilonidal.RESULTADOS:El seno pilonidal se detectó en el 22,5 % (12,5 % fosas asintomáticas, 10 % sintomáticas) de las pacientes con síndrome de ovario poliquístico y en el 1,7 % del grupo control ( p < 0,001). No se observaron diferencias entre los dos grupos en términos de IMC ( p = 0,219). Los antecedentes familiares fueron similares entre los grupos de casos y controles ( p = 0,520). No se observaron diferencias significativas entre los dos grupos en términos de higiene insuficiente y tiempo de sedentarismo diario ( p = 0,763, p = 0,706). El análisis multivariante mostró que el riesgo de seno pilonidal fue significativamente mayor en pacientes con antecedentes familiares positivos ( p = 0,008).LIMITACIONES:El número de pacientes en los grupos de casos y controles en el estudio fue limitado. Además, es posible que el grupo de control no refleje completamente a la población general, ya que está compuesto solo por pacientes que acudieron a la consulta externa de cirugía general y ginecología por otras razones. El grupo de control no fue emparejado por edad.CONCLUSIONES:En nuestro estudio encontramos que la prevalencia de seno pilonidal fue significativamente mayor en pacientes con síndrome de ovario poliquístico. Consulte Video Resumen en http://links.lww.com/DCR/B945 . (Traducción-Dr. Ingrid Melo ).

MANAGEMENT PRINCIPLES OF INCIDENTAL THYROID 18F-FDG UPTAKE IDENTIFIED ON 18F-FDG PET/CT IMAGING

PURPOSE

The purpose of this study is to determine the clinical significance of incidental thyroid 18F-FDG PET/CT uptake in oncology patients with the focus achieving the most appropriate management of this challenging situation.

MATERIALS AND METHOD

Two thousand five hundred and eighty 18F-FDG PET/CT studies performed at our institute in the past 4 years were retrospectively reviewed. Patients with incidental FDG uptake in the thyroid gland were further analysed.

RESULTS

The prevalence of incidental FDG uptake in thyroid gland was 7.6% (129 patients). 26 patients (20.1%) had diffuse 18F-FDG PET/CT uptake, 103 patients (79.1%) had nodular uptake in thyroid gland. All diffuse uptake patients who were further examined diagnosed to be a benign condition. 53 patients in the nodular uptake group were further examined and the final histopathology examinations revealed an 18.8% malignancy rate. SUV max values ranged from 2 to 21.8 with a significant highness in malignant lesions.

CONCLUSION

18F-FDG PET/CT uptake in the thyroid gland may be diffuse or nodular. Diffuse uptake needs no further examination as it usually accompanied by benign thyroid disorders. Patients with nodular uptake whose general condition is good should be further examined due to high rates of malignancy.

Can HALP (Hemoglobin, Albumin, Lymphocytes, and Platelets) Score Differentiate Between Malignant and Benign Causes of Acute Mechanic Intestinal Obstruction?

Background: Hematological parameters, including albumin and hemoglobin (Hb) levels and lymphocyte counts, are low-cost tests that can be used to determine inflammation and nutritional status. Recent studies have shown that inflammation plays a very important role in the development of carcinogenesis. Materials and Methods: The authors aimed to investigate whether preoperative hemoglobin, albumin, lymphocyte, and platelet (HALP) score can distinguish between benign and malignant causes in patients who are admitted to hospital and operated due to acute mechanical intestinal obstruction (AMIO). The patients were divided into two groups etiologically. Group 1 included the AMIO cases, which developed from benign causes, while Group II contained the AMIO cases, which developed as a result of malignancy. HALP score was calculated based on the latest preoperative Hb, albumin, lymphocyte, and platelet values of patients. Results: HALP variable was an independent prognostic factor (p < 0.001) in determining malignancy (odds ratio = 0.91; 95% confidence interval [CI] = 0.882-0.930). Based on the results, when a cutoff value <23.94 was used for HALP score in receiver operating characteristic analysis, sensitivity for determining the malignancy was 85%, while specificity was 78% (Area under the curve [AUC] ± standard error = 0.86 ± 0.029; 95% CI = 0.80-0.91; p < 0.001). Conclusions: The HALP score could be a useful parameter for the clinician in distinguishing between AMIO due to benign and malignant origins.

Performance of Residents During Laparoscopic Cholecystectomy: Is Self-assessment Reliable?

BACKGROUND

To compare the self-assessment of surgical residents and observers (faculty members and nurses) during laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

A prospective observational study was conducted between February 2020 and July 2020 at a medical school hospital. Seventy-four LC surgeries were performed by surgical residents in the presence of faculty members. A self-assessment of the technical and nontechnical performance of the residents was requested. The self-assessment of residents was compared with observer evaluations using the Kruskal-Wallis test. Gwet AC2 fit coefficient was used to determine the consistency between the observers' and residents' assessments. Bland-Altman plots were generated with 95% limits of agreement to describe the agreement between the total scores of the observers.

RESULTS

The self-assessment of residents had a statistically significant higher score when compared with observers (faculty and nurses) (P<0.001). However, no significant difference was observed between the total scores given by the observers (faculty members and nurses) (P>0.05). There was a moderate agreement between the resident versus faculty members [0.503; 95% confidence interval (CI), 0.430-0.576] and resident versus nurse (0.518; 95% CI, 0.432-0.605) when evaluating technical skills. However, there was substantial agreement between faculty members and nurses (0.736; 95% CI, 0.684-0.789). Postoperative pain was significantly correlated with resident self-assessment (P=0.022).

CONCLUSION

The self-assessment scores of surgical residents in LC operations were overestimated compared with observer assessments.

Could lymphocyte to C-reactive protein ratio predict the prognosis in patients with gastric cancer?

BACKGROUND

Development or progression of inflammation in neoplastic diseases is known to be part of the disease. Lymphocyte to C-reactive protein ratio (LCR) is a new indicator showing the inflammatory state. The aim of this study is to show the clinical importance of the relationship between the preoperative LCR and the prognosis of patients with gastric cancer.

METHODS AND PATIENTS

We evaluated gastric cancer patients, who underwent surgery between 2010 and 2015. LCR and neutrophil-to-lymphocyte ratio (NLR) were calculated from pre-treatment of complete blood counts. Both ratios were compared to the perioperative outcomes and median survival times. Association between LCR and postoperative tumour stage was studied by using multivariate analysis with other clinicopathological variables.

RESULTS

A total of 123 patients were included. The mean age of the patients was 65.36 ± 10.08. Preoperative low LCR value was associated with advanced tumour stage, adjacent organ invasion, lymph node metastasis and postoperative early complications. The receiver operating characteristic analysis results showed that LCR and NLR parameters were significant (CI 0.718-0.886; 95%); P < 0.001, CI 0.534-0.732; 95%). Cut-off value being 193, the mean survival of patients who had LCR values of overcut-off value was found to be significantly higher compared with the patients with lower LCR values (P < 0.001).

CONCLUSION

LCR, a simple calculated ratio of values obtained from easy and widely available serum indicators could be an effective prognostic marker with gastric cancer.

Timing of laparoscopic cholecystectomy in acute cholecystitis

Background

Timing of laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) is still debated.

Aims

The aim of this study was to investigate the effect of timing on operative results; from the first appearance of symptoms to the operation.

Methods

The study included 57 sequential patients operated laparoscopically for AC. Patients operated within the first 3 days of admission (Group 1), those operated between 4^th and 7^th days (Group 2) and those operated after 7^th day (Group 3) were evaluated and compared with respect to demographics, time from admission to operation, duration of operation, adhesion score, complications, conversion rates, duration of hospital stay, morbidity and mortality rates, bile culture results, and histopathological evaluation.

Results

A total of 63% of the patients were female and 21 (37%) were male. The mean age was 48 years (range, 21-74). There was no significant difference among the groups with respect to demographics (P > 0.05, for each). The duration of operation was significantly shorter in Group 1 than both Groups 2 and 3 (P < 0.05 and P < 0.001, respectively). Duration of operation was also significantly shorter in Group 2 than Group 3 (P < 0.001). Group 1 had significantly fewer adhesions compared to Group 2 and Group 3 (P < 0.05 and P < 0.001, respectively), and no significant difference was found between Group 2 and Group 3 (P > 0.05). Duration of hospital stay was significantly shorter in Group 1 compared to Group 2 and Group 3 (P < 0.001) and also was significantly shorter in Group 2 than Group 3 (P < 0.05). Group 1 had significantly lower rate of culture proliferation than Group 3 (P < 0.001), whereas no significant differences were evident in other inter-group analyses (P > 0.05, for each).

Conclusion

LC can safely be performed within 7 days of admission in cases of AC.

Transrectal vacuum treatment for low colorectal anastomotic leaks

BACKGROUND

Anastomotic leakage after rectal resection is a major complication which increases the rates of morbidity and mortality. A small number of patients with generalised peritonitis need radical surgical treatments. Stable patients with local peritonitis can be treated conservatively. The aim of this study is to evaluate the effects of transrectal vacuum treatment on the healing of low colorectal anastomotic leaks.

METHODS

Medical records of fourteen patients managed conservatively with transrectal vacuum treatment for anastomotic leakage after rectal resection between September 2015 and September 2018, were retrospectively reviewed. Anastomotic leakage was documented and evaluated with computerised tomography and rectosigmoidoscopy.

RESULTS

10 of 14 patients had successful closure of the perianastomotic abscess cavity after a mean of 19 days of vacuum treatment. 2 patients in this group had stricture on the anastomotic site as a late complication which was successfully treated with repeated dilatations. 4 of 14 patients had eventually a permanent sigmoid colostomy.

CONCLUSION

Our results suggest that transrectal vacuum treatment can be safely used to all stable patients without generalised peritonitis in the management of low colorectal anastomotic leakages.

KEY WORDS

Anastomotic leakage, Rectosigmoidoscopy, Vacuum treatment, VAC.

The Efficiency of Laparoscopic Common Bile Duct Exploration in Endoscopic Retrograde-Cholangiopancreatography-Limited Setting in a Peripheral University Hospital

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the effectiveness, safety, and outcomes of these methods. In addition, it is aimed to review the feasibility of laparoscopic method in rural areas. Methods: Seventy-one patients were analyzed retrospectively. Patients were divided into two groups as open and laparoscopic surgical method. These groups were analyzed comparatively in terms of complications and costs. Subgroups were formed from patients who underwent T-tube drainage, primary closure, and biliary anastomosis as choledochotomy management. As a secondary outcome, these three subgroups were investigated in terms of complications and cost. Results: The cost was lower in open method compared to laparoscopic method (484$, 707$, P = .002). There was no significant difference in postoperative complications between groups (P = .257). While the mean hospital stay was longer in the open group, the operation time was shorter (P = .002, P = .03). The mean length of hospital stay in the T-tube group was significantly higher than the primary closure (P = .001). The cost in the T-tube group was significantly higher than the primary closure and biliary anastomosis groups. Conclusion: Laparoscopic CBD exploration by experienced surgeons in endoscopic retrograde-cholangiopancreatography-limited settings is an effective and safe method in the treatment of choledocholithiasis. This procedure should not be limited to reference centers and should be performed safely in rural areas by well-trained surgeons.

Association between Shoulder Range of Motion and Pain Catastrophizing Scale in Breast Cancer Patients after Surgery

Background

Prolonged survival period as a result of early diagnosis and treatment in breast cancer has increased the importance of postoperative morbidities. The aim of the present study was to investigate the association of pain ca-tastrophizing with shoulder pain in patients with decreased shoulder range of motion in the postoperative period.

Patients and Methods

The present study included 53 patients who underwent surgery due to breast cancer. Patients who had bilateral mastectomy, distant metastases, cervical-cranial originated lesions, patients with problems involving one of the shoulders or upper extremities before the operation, and patients with cognitive impairment, heart failure, or low albumin levels (liver parenchyma disease or renal failure) were excluded. Shoulder range of motion was measured in the postoperative period, and two study groups were established: one with a limited shoulder range of motion level and the other with a normal level. Effects of pain catastrophizing and shoulder pain severity on shoulder range of motion limitation were compared between the two groups.

Results

The average age of 53 female patients who had breast surgery was 52.3 ± 10.5 years. In the group with limited shoulder range of motion, the median pain catastrophizing scale value was 27 (range 5-32) and the shoulder pain severity score was 4 (range 0-8), while in the group with normal shoulder range of motion these values were 11 (range 3-39) and 2 (range 0-6), respectively (p < 0.05). In addition, it was found that factors such as surgical treatment modality and postoperative radiotherapy did not significantly affect shoulder range of motion limitation.

Conclusion

Determining the pain catastrophizing scale of patients and controlling pain in the early postoperative period could have positive effects on shoulder range of motion.

Lymphocyte-C-reactive protein ratio: a putative predictive factor for intestinal ischemia in strangulated abdominal wall hernias

PURPOSE

The purpose of this study was to investigate whether it is possible to estimate systemic inflammation and intestinal ischemia in incarcerated hernias using the lymphocyte-C-reactive protein ratio (LCR).

METHODS

A total of 116 patients who underwent an emergency operation due to incarcerated abdominal wall hernia were investigated retrospectively. The patients with incarcerated hernias were divided into two groups: those who did not undergo intestinal resection and those who underwent intestinal resection due to strangulation. The two groups were analyzed based on sex, surgical operation (open, laparoscopic), length of stay, complications and mortality rates as well as preoperative period laboratory analyses, such as white blood cell, neutrophil, thrombocyte, and lymphocyte counts and C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and LCR values.

RESULTS

Twenty-five patients (21.6%) underwent intestinal resection due to strangulated hernia. Neutrophil count, lymphocyte count, CRP, platelet count, NLR, and LCR were significantly different in the strangulated hernia group. Receiver operating characteristic (ROC) analysis results showed that an LCR level below 0.02 had 80% sensitivity (58-92%) and 80.2% specificity (70-87%) for the diagnosis of strangulation.

CONCLUSION

A low preoperative LCR level in incarcerated hernias could be used as a bioindicator that helps to estimate the intestinal ischemia.

Recurrent acute pancreatitis in a patient with both gallbladder and cystic duct agenesis and polycystic liver disease

Agenesis of the gallbladder and cystic duct is a rare congenital anomaly occurring in <0.1% of the population. However, combined gallbladder and cystic duct agenesis (CDA) with polycystic liver disease associated with recurrent acute pancreatitis (RAP) has not been reported earlier. Herein we report a case of a 36-year-old female patient who was admitted to the hospital and successfully treated for acute pancreatitis most probably caused in the background of gallbladder and CDA with polycystic liver disease. In case of non-visualization of gallbladder with the presence of biliary symptoms after repeated ultrasonographic examinations, advanced techniques like MRCP, computed tomography, EUS and even endoscopic retrograde cholangiopancreatography (ERCP) to visualize biliary anatomy must be conducted before any surgical intervention. We present a case of gallbladder and CDA causing RAP by the formation of microlithiasis treated successfully with ERCP and without any unnecessary surgery, its management and review of the literature is assessed.

Primary hydatid cyst localized in soft tissue during pregnancy

Hydatid cyst in pregnancy is a rare condition. Moreover, it is very rare that it is in the soft tissue other than the liver. In this case, there are no data in the literature on treatment options, but only experience in case presentations. We present a patient who had severe pain during pregnancy due to isolated soft tissue hydatid cyst disease in this case report.

Does Sacrococcygeal Angle Play a Role on Pilonidal Sinus Etiology?

The predisposing factors for the development of sacrococcygeal pilonidal disease (SPD) still remain undetermined. Here, we investigate the sacrococcygeal angle as a possible predisposing factor for the development of disease. Consecutive male patients admitted to our clinic with the diagnosis of SPD were included. Sex, age and BMI matched healthy controls without SPD were enrolled to the study. The predefined sacrococcygeal angles of patients and controls were measured on lateral pelvic radiographs by a single experienced radiologist. Thirty patients were included in each group. Sacrococcygeal angles of patients and control group were measured as 37.3±14.5 and 36.81±10.23 in patients and controls, respectively. The difference with respect to sacrococcygeal angle was not statistically significant between two groups. Sacrococcygeal angle which is the main skeletal determinant of intergluteal sulcus is not a predisposing factor for the development of sacrococcygeal pilonidal disease.

The role of n-butyl-2-cyanoacrylate in the repair of traumatic diaphragmatic injuries

Diaphragmatic injuries either by blunt or penetrating trauma require prompt surgical intervention and are often exigent to repair. N-butyl-2-cyanoacrylate (n-butyl-2-CA) is a tissue adhesive which has gained wide application in many areas of surgery including emergency. To repair the extensive injuries of the diaphragm it may be necessary the use of synthetic mesh by fixing it with sutures or staples. The use of tissue adhesives may circumvent the potential problems associated with mesh fixation. This study aimed to evaluate the efficacy and safety of tissue adhesives usage for mesh fixation in diaphragmatic injury repair. Twenty-four rats were divided into 3 groups each of them containing 8 rats. A 1- cm diaphragmatic defect was created in all rats. The defect was repaired by polypropylene suture in Group I, by mesh fixed with sutures in group II and by mesh fixed with n-butyl-2-CA in group III. The rats were sacrificed after 1 month. The episode of hernia and the adhesions were assessed by adhesion density score. Also, the abscess and inflammation in the repaired tissue were evaluated microscopically. The Kruskal-Wallis test was performed for the histopathological analysis. No diaphragmatic hernia was detected in any group. While Group III had higher adhesion density scores than group I (P: 0.027), there were no differences between group III and II (P: 0.317) and group II and I (P = 0.095) regarding adhesion density scores. The inflammation grade was higher in group III than group I and II (P < 0.001) and was higher in group II than group I (P < 0.05). There was no differences between each groups, concerning microabcsess formation (P > 0.05). Repair of traumatic diaphragmatic injury in penetrating wound, with polypropylene mesh fixed by n-butyl-2-CA in rats appears to be as efficacious and safe as conventional methods in early period. However, further experimental and clinical study are needed to compare the long-term results of adhesive mesh repair with those of the traditional sutured techniques.

Same-day colonoscopy preparation with Senna alkaloids and bisacodyl tablets: A pilot study

AIM: To evaluate the efficacy of same-day bowel preparation with Senna alkaloids combined with bisacodyl tablets in routine colonoscopy procedures.

METHODS: Between March and June 2013, a same-day bowel preparation was implemented in our endoscopy unit. The preparation consisted of a semi-liquid, fiber-free diet one day prior to the procedure, with two bisacodyl tablets after lunch and dinner, and 250 mL of Senna alkaloid with 1.5 L of drinking water at 6 am the day of the procedure. The quality control parameters of colonoscopy were evaluated and implemented according to the guidelines of the American Society for Gastrointestinal Endoscopy. The pre-procedure, during-procedure and post-procedure patient data were collected and analyzed: (1) pre-procedure (age, gender, comorbid diseases, colonoscopy indications, complete lack of compliance with the bowel preparation protocol); (2) during-procedure (sedation dose, duration of colonoscopy, withdrawal time, cecal intubation rate, polyp detection rate, Boston Bowel Preparation Scores and presence of foam and clear liquid); and (3) post-procedure (visual analogue scale score, pain during the procedure, patient satisfaction and premature withdrawal due to the insufficient bowel preparation).

RESULTS: A total of 75 patients were included in this study with a mean age of 54.64 ± 13.29 years; 53.3% (40/75) were female and 46.7% (35/75) were male. A complete lack of compliance with the bowel preparation protocol was seen in 6.7% of patients (5/75). The mean total duration of colonoscopy was 16.12 ± 6.51 min, and the mean withdrawal time was 8.89 ± 4.07 min. The cecal intubation rate was 93.8% (61/64) and the polyp detection rate was 40% (30/75). The mean Boston Bowel Preparation Score was 7.38 ± 1.81, with the following distribution: right colon, 2.34 ± 0.89; transverse colon, 2.52 ± 0.67; left colon, 2.52 ± 0.63. The mean visual analogue scale score was 4.59 ± 1.57. Due to insufficient bowel preparation, seven patients (7/75; 9.3%) were asked to repeat the procedure. Of these, five patients had poor or modest compliance with the protocol, and two patients reported constipation. Premature withdrawal due to insufficient bowel preparation was 2.7% (2/75). The overall satisfaction with the protocol was 86.7% (65/75), with patients reporting they would prefer the same protocol in a repeat procedure.

CONCLUSION: The same-day administration of Senna alkaloids appears to be a safe and effective bowel cleansing protocol for colonoscopy procedures.

A new prognostic strategy for gastric carcinoma: albumin level and metastatic lymph node ratio

AIM

We evaluated the prognostic significance of preoperative serum albumin value and metastatic lymph node ratio for gastric cancer patients.

METHODS

We studied patients diagnosed with gastric carcinoma in the first Department of Surgery, Bezmialem Vakif Gureba Training and Research Hospital between January 2004 and December 2010; the patients were studied retrospectively.

RESULTS

A total of 67 patients with a mean age of 58.7 ± 11.4 years were included in the study. The majority of patients were male (N.=53 male; N.=14 female). Most patients were in an advanced stage of the disease (stage III-IV) on admission (67.2%). We classified patients according to albumin value as "normal" Group 1 (83%) and "hypoalbuminemic" Group 2 (17%). With albumin, age, resection type, perineural invasion, and ratio of metastatic lymph nodes, T and TNM stages were significant predictors of cancer-specific survival.

CONCLUSION

As a result, irrespective of mechanism, pre-operative evaluations of albumin and metastatic lymph node ratio should be performed to stratify the patients for risk analysis and prognosis. A level less than 3.5 g/dL is a negative prognostic factor for resectable gastric cancers.

The use of fibrin glue without surgery in the treatment of pilonidal sinus disease

Pilonidal sinus disease is a common disabling condition affecting the natal clefts of the buttocks. We analyze the role of fibrin glue in the treatment of selected patients with pilonidal sinus disease. Forty patients diagnosed with pilonidal sinus disease at Vakif Gureba Training and Research Hospital were treated between December 2007 and December 2011. Recurrence was noted in four patients (10%). Ninety percent of patients had no recurrence one year later (95% confidence interval: 0.85-0.95). This procedure is suggested as a first line of treatment for patients with no prior history of infection and who have only one sinus orifice.

Effect of orally administered simvastatin on prevention of postoperative adhesion in rats

AIM

Formation of adhesions in the abdominal region appearing after abdominal pelvic surgery lead to infertility, chronic pelvic pain, intestinal obstructions, difficulty and morbidity at the following operations, and increased morbidity. The aim of our study is to examine the effectiveness of orally administered simvastatin on preventing the postoperative adhesion.

MATERIALS AND METHODS

20 male Wistar Albino rats weighing 230-250 gr were used. The rats were housed for 12 hours day and 12 hours night cycles in cages and were divided into two groups, namely study and control group. Microscopic evaluation of adhesion was assessed under 5 main topics which are the signs of inflammatory response; inflammation, activation, fibroblast activity, vascularity, presence of giant cell. Activation was scored as follows: (0) no activation, (1) while activation was accepted as present the score for other parameters was evaluated between 0 to 3 according to the increased severity. After evaluating all topics separately, the average of all scores has been assessed in both groups.

RESULTS

As a result of the macroscopic evaluation of postoperative intra-abdominal adhesions, the percentage of adhesion in simvastatin applied group was found to be 0.8 ± 0.17. This value was calculated as 0.6 ± 0.2 in the control group. Regarding the severity of adhesion, while in the simvastatin applied group the value was found to be 9.1 ± 4, in the control group it was 6.8 ± 3. The general adhesion score was found to be 7.7 ± 4.2 in simvastatin applied group and 5.1 ± 3.7 in control group.

CONCLUSION

In this experimental study it was showed that orally administered simvastatin has no significant effect on preventing formation of postoperative adhesions.

Does the Difficulty of Laparoscopic Cholecystectomy Differ Between Genders?

Some studies have shown that severe fibrosis and anatomical anomalies are more common in men, and subsequently, laparoscopic cholecystectomy is more difficult in male than female patients. We aimed to evaluate the effect of gender in patients who underwent laparoscopic cholecystectomy, with regard to the conversion rate, the differences in histological inflammation severity, and anatomical difficulty. We reviewed retrospectively 915 patients with symptomatic cholelithiasis who underwent laparoscopic cholecystectomy in the First Department of General Surgery at Vakif Gureba Training and Research Hospital. Patients were divided into male (group 1) and female (group 2) groups. Both groups were compared with demographic criteria, the type of inflammation found on resected gallbladder, anatomical difficulty, gallbladder perforation during the operation, length of operation time, conversion rate, and omental and organ adhesions to the gallbladder. Of the 915 patients, 173 patients (19 %) were males (group 1), and 742 (81 %) were females (group 2). Mean age was 53 ± 12 (range 22 to 80) years in group 1 and 49 ± 13 (range 17 to 85) years in group 2. The average duration of surgery was 71 ± 33 min (range 20 to 160) in group 1 and 58 ± 27 min (range 15 to 135) in group 2 (p < 0.001). The conversion rate between groups was significantly different (p < 0.05). Inflammatory findings (acute or chronic) in resected gallbladder between groups 1 and 2 were significantly different (p < 0.0001 and p < 0.05, respectively). The frequency of adhesions between the gallbladder and omentum and other organs was higher in male (p = 0.003 and p = 0.0006, respectively). Anatomical difficulty was more prominent in male patients (p < 0.0001). The findings of higher scores of anatomical difficulty in operation and inflammation in cholecystectomy specimens, as well as higher rates of conversion in males, suggested that laparoscopic gallbladder surgery is more difficult in men.

"Diagnostic value of MRCP in biliary pancreatitis: result of long-term follow-up"

AIM

Magnetic resonance cholangiopancreatography (MRCP) has increasingly been used to evaluate the common bile duct. This study was to determine the role of MRCP instead of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis.

METHODS

A total of 81 patients with mild or moderate biliary pancreatitis who underwent MRCP and were treated in our department with selective ERCP between May 2001 and July 2007 were entered into a prospective database.

RESULTS

MRCP was considered abnormal in 13 patients. Ten patients underwent ERCP. Three patients did not undergo ERCP due to protocol violations. In nine patients, stone extraction was performed. The remaining patient who had dilatation of the CBD underwent ES. The false positive rate of MRCP was 10%. The median follow-up of overall patients was 36 months (range 23-99 months). The patients with normal MRCP had a median follow-up of 39.5 months (range 23-99 months). During the follow-up period in the normal MRCP group, five patients were diagnosed with recurrent biliary pancreatitis, of which three underwent ERCP (7.4%). There was no disease-related mortality during this period.

CONCLUSION

In conclusion, the use of MRCP in acute biliary pancreatitis is safe and may be recommended as a tool to aid in the selective use of ERCP.

Delayed presentation of posttraumatic diaphragmatic hernia

BACKGROUND

Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia.

METHODS

A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed.

RESULTS

Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected.

CONCLUSION

Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.

Spontaneous biloma managed with endoscopic retrograde cholangiopancreatography and percutaneous drainage: a case report

Introduction

Spontaneous biloma formation is a very rare condition, which mandates immediate treatment.

Case presentation

An 80-year-old Caucasian man was referred to our department with a diagnosis of intra-abdominal collection located in his right upper quadrant. Further radiological examination demonstrated multiple calculi in his gallbladder and common bile duct. Our patient underwent endoscopic retrograde cholangiopancreatography and the stones in the common bile duct were extracted. Percutaneous drainage of the abdominal collection revealed a spontaneous biloma formation. Continuous drainage of bile persisted for one week, so endoscopic retrograde cholangiopancreatography was repeated and a 10Fr stent was placed; subsequently the biliary leak ceased and our patient was discharged. A control abdominal computed tomography did not show any residual fluid collection.

Conclusion

Spontaneous biloma formation is a very rare incidence; awareness is necessary for prompt recognition and treatment.

Venous air embolism during laparoscopic cholecystectomy

Vascular air embolism is a rare and potentially life-threatening event. In this study, a case of venous air embolism during laparoscopic cholecystectomy due to an injured inferior vena cava is presented. Anesthesiologists and surgeons must be aware of this dangerous complication. Emphasis is given to the prevention and prompt recognition of this event and to the use of all available tools in the management of cardiovascular complications.

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM

To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy.

METHODS

Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure.

RESULTS

The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen.

CONCLUSION

Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Mechanical lithotripsy and/or stenting in management of difficult common bile duct stones

BACKGROUND

Mechanical lithotripsy and/or stent insertion is the alternative therapeutic approach in difficult endoscopic retrograde cholangiopancreatography (ERCP) case. This study was designed to investigate the appropriate treatment for extraction of bile duct stones in difficult cases of ERCP.

METHODS

Between 2000 and 2008, 744 ERCP procedures were performed in 592 patients with choledocholithiasis in our endoscopy unit. The demographic features, and clinical and laboratory findings were collected from a prospectively held database. Bile duct calculi were extracted by basket and/or balloon catheter following ERCP and sphincterotomy. Patients with retained stones were regarded as difficult cases. These patients were treated with mechanical lithotripsy and those with incomplete clearance of stones underwent stent placement.

RESULTS

Two hundred and forty-five patients (41%) were male and 347 (59%) were female with a mean age of 58 years (range 19-95 years). Stones were impacted in 27 patients (5%). Stone extraction was performed by basket and/or balloon catheter in 610 ERCP procedures, and lithotripsy was performed in 70 ERCP procedures. Forty-four patients underwent stent insertion, and 20 underwent stent replacement. Morbidity occurred in 39 patients (5%), with no mortality associated with the procedure. Hemorrhage occurred in 9 patients and basket impaction in 4. Mild pancreatitis and cholangitis developed in 12 and 11 patients, respectively.

CONCLUSION

Difficult cases of bile duct stones can be treated successfully with lithotripsy, and a stent should be applied when the common bile duct cannot be cleared completely.

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy.

METHODS: Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure.

RESULTS: The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen.

CONCLUSION: Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.

Dieulafoy lesion in the stomach

Dieulafoy disease is an uncommon cause of gastrointestinal system bleeding. Although the exact cause is not known, it is characterized by bleeding from abnormal submucosal vessels. There are many methods for diagnosis and treatment. In this case, a patient with a long-time undiagnosed stomach Dieulafoy lesion had a surgical resection. During the postoperative period the patient was discharged without any complication.

Recurrent laryngeal nerve palsy after thyroid surgery

The identification of the risk factors associated with the increased incidence of the nerve injury is of paramount importance. Twenty-nine of 581 patients who developed recurrent laryngeal nerve palsy after thyroidectomy were analyzed retrospectively. There were 23 women (79%) and 6 men (21%), with a mean age of 45.6 years (range, 22-66 years). Eleven patients had right vocal cord paralysis, 8 had left vocal cord paralysis, and 10 patients had bilateral involvement. Ten patients underwent near total thyroidectomy (34.4%), eight patients underwent bilateral subtotal thyroidectomy (27.5%), six patients underwent total thyroidectomy (20.7%), and five patients underwent unilateral lobectomy (17.2%). Four of 10 patients with bilateral vocal cord paralysis had a unilateral nerve injury detected with laryngoscopy before surgery. Only five patients developed permanent vocal cord paralysis (17%). Three patients with permanent paralysis underwent reoperative thyroid surgery and had a total lobectomy. One patient required a tracheostomy, and arytenoidectomy was performed in one patient at a later follow-up period. Most recurrent laryngeal nerve palsy after thyroidectomy was transient. Permanent paralysis is associated with reoperative thyroid surgery.

Risk factors of morbidity and mortality in patients with perforated peptic ulcer

PURPOSE

Peptic ulcer perforation is a serious problem that leads to high complication and mortality rates. The aim of this prospective clinical study was to evaluate complications and possible risk factors for peri-operative morbidity and mortality in patients with perforated peptic ulcer (PPU).

MATERIAL AND METHODS

Ninety-seven patients hospitalized for PPU at the Department of Surgery, Vakif Gureba Training and Research Hospital, between March 1998 and December 2004 were analysed.

RESULTS

The mean age of patients was 38.6 years. Ten patients had 19 co-morbidities. The mean hospitalisation time was 7.1 days. Twenty-one complications in 15 patients occurred. Overall morbidity and mortality rates were 15.5% and 5.2% respectively. Multivariate logistic regression analysis of 97 patients revealed that age (p < 0.006) and late admission (p < 0.001) were linked to morbidity. The mortality rate tended to be associated with advanced age, therapeutic delay and co-morbidities.

CONCLUSIONS

Increased patients' age and the therapeutic delay, predicted outcome after surgical treatment of PPU. Morbidity and mortality could be reduced by avoiding delays in diagnosis and treatment, especially in older patients, and by instituting proper treatment of any coexisting medical illness.

Idiopathic abdominal cocoon: report of a case

The abdominal cocoon is a rare disease in which there is total or partial encapsulation of the small bowel by a fibrous membrane. A correct diagnosis is not often made pre-operatively. Awareness of this rare cause of surgical emergency may prevent delay in treatment and avoid unnecessary procedures for the patient, such as bowel resection. We report a patient diagnosed with abdominal cocoon who was subsequently treated.

Closure of fascial defect at trocar sites after laparoscopic surgery

As laparoscopic surgery evolves, a growing number of different abdominal operations can now be performed. This necessitates the use of multiple large trocars. Herniation through the fascial defect created by trocar entry in laparoscopic interventions has been reported at a rate of 1-6%. We describe a simple closure technique for fascial defects at trocar sites after laparoscopic surgery. To facilitate the closure of the fascial defects of > or = 10 mm trocar entry sites, the surgeon places the upper end of a dissecting forceps through the fascial defect and tilts it so that the abdominal of the peritoneum comes into contact with its flat surface. The assistant retracts the skin and subcutaneous tissue and the "J" needle with the appropriate suture material is then used to take a stitch through the fascia under direct vision. The sharp end of the needle is prevented from coming into contact with any deeper structure as it slides on the flat surface of the dissecting forceps. The stitch is then pulled up to lift the edge of the fascia and the needle is passed from the opposite edge of the fascia in the same manner and then the suture is ligated. The aforementioned technique is easy to perform and facilitates the closure of the fascial defect at trocar sites, and there is no extra cost for the procedure.

Endoscopic stenting for selected cases of biliary fistula after hepatic hydatid surgery

BACKGROUND

Biliary fistula develops in 4%-28% of patients after hepatic hydatid disease (HHD) surgery. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are helpful in the treatment of this complication, persistent fistulas may occur. We therefore conducted a study to evaluate the efficacy of endoscopic biliary stenting in the treatment of biliary fistulas after HHD.

METHODS

In this study, 84 patients who underwent ERCP for postoperative biliary fistula due to HHD were evaluated. Group I included 70 patients treated with only ES, and group II included 14 patients who underwent biliary stenting as their initial treatment. Demographic data, complications, the results of treatment and the reasons for the failure were compared between two groups.

RESULTS

Ninety-five ERCPs were performed. In 63 patients, biliary fistulas were successfully treated with only ERCP and ES. However, 7 patients underwent repeat ERCP and stent placement because of persistent fistula. Biliary stenting was initially performed in 14 patients. The average time for closure of the fistula was 14 +/- 10 days and 7 +/- 3 days in group I (7 patients with repeat ERCP were excluded) and group II, respectively (p = 0.007). There was no statistically significant difference in the complication rates between the groups.

CONCLUSIONS

Although ES is effective in the treatment of biliary fistula after HHD surgery, endoscopic biliary stenting may be considered as the initial procedure in patients with biliary stricture, incomplete clearance of hydatid material in the bile duct, and persisting biliary fistulas after treatment with ERCP and ES.

Femoral hernia: a review of 83 cases

We evaluate the factors that affect morbidity and mortality in patients who underwent surgery due to femoral hernia. The medical records of 83 patients who underwent femoral hernia repair between January 1996 and June 2004 were retrospectively analyzed. The femoral hernias were repaired either with McVay or mesh plug hernioplasty. Sex, age, surgical repair technique, presence of incarceration/strangulation, incarcerated/strangulated organs, postoperative complications, duration of hospitalization, recurrence rate, and factors that affect mortality and morbidity were studied. There were 83 patients with femoral hernia in our study. Patients' age ranged from 10 to 75 years (mean age was 46.84) with a predominance of female (71%). Thirty-six patients (40%) underwent emergency surgery with the diagnosis of strangulation or incarceration of femoral hernia. Seventeen patients had strangulation and underwent resection; eleven of these patients had omentum in the hernial sac, whereas six patients had intestines. Four of these patients underwent laparotomy. The remaining 19 patients had incarceration and underwent simple reduction of hernial sac content without resection. Forty-seven (60%) patients underwent elective surgery. McVay technique was used for 79 patients, while the other four patients were treated with mesh-plug. Twelve patients (15%) developed a variety of complications (nine patients (25%) in emergency, three patients (6%) in elective group). There was one mortality. Recurrences occurred in two patients. Femoral hernia is an important surgical pathology with high rates of incarceration/strangulation and intestinal resection. Emergency surgery can increase morbidity and mortality especially in the elderly. Early elective surgery may reduce complication.

Comparison of surgical techniques for treatment of benign toxic multinodular goiter

Controversy remains regarding the best surgical approach for toxic multinodular goiter (MNG). The aim of this study was to evaluate the results of various thyroid operations for managing toxic MNG. A group of 100 patients with toxic MNG were divided into three groups and managed with total thyroidectomy (TT; group I, n-17), near-total thyroidectomy (NTT; group II, n = 48), or bilateral subtotal thyroidectomy (BST; group III, n = 35). Patients were compared with regard to age, gender, surgical operations, complications, thyroid hormone status, duration of hospitalization, and the reoperation rate for incidentally found thyroid carcinomas. There were 14 men (14%) and 86 women (86%) with a mean age of 47.03 +/- 13.56 years (range 19-77 years). After the operation two patients had a hematoma, and one patient had a seroma. Four patients had unilateral vocal cord paralysis, and one had permanent paralysis. Moreover, 18 patients had transient and 2 patients permanent hypocalcemia. There was no significant difference between the groups regarding complications (p < 0.05). Permanent hypothyroidism was achieved in all patients in group I and 44 patients (92%) in group II, whereas in group III only 10 (29%) patients had hypothyroidism. Conversely, hyperthyroidism, both subclinical and clinical, was noted only in group III (12 patients, 34%) during follow-up. We think that TT and NTT are safe, effective approaches in the treatment of toxic MNG, preventing recurrence of thyrotoxicosis and reoperation for incidentally found thyroid cancers. The complication rates for TT and NTT were similar to that for BST. Hence these operation should be considered for patients referred for surgical treatment of toxic MNG.

Umbilical Pilonidal Sinus Disease: Predisposing Factors and Treatment

Pilonidal sinus disease is a common problem of sacrococcygeal region. However, it is also observed in the periumbilical area. There are only a few reports about umbilical pilonidal sinus in the literature. In this study, 26 patients (24 men (92 %), 2 women (8 %) with a mean age of 22 years) with umbilical pilonidal sinus disease were included. Predisposing factors, patient characteristics, treatment modalities, and their results have been studied. Male sex, young age, hairiness, deep navel, and poor personal hygiene were found to be predisposing factors. Twenty-five patients were treated conservatively. However, two patients failed to respond to conservative treatment. Those patients underwent surgery where umbilectomy was carried out without reconstruction. One patient was also operated on for the preoperative misdiagnosis of irreducible umbilical hernia. Patients were followed for 14-96 months. We recommend conservative treatment in patients with umbilical pilonidal sinus. Surgery should be performed in recurrent cases resistant to conservative treatment. The importance of differential diagnosis of umbilical pilonidal sinus from other umbilical pathologies is also emphasized.

The Effect of the Degree of Histologic Inflammation on Gallbladder Perforation During Laparoscopic Cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) is the gold standard operation for the treatment of symptomatic gallstones. Intraoperative gallbladder perforation is a common complication encountered during the surgery. The purpose of this study was to identify the effects of inflammation on gallbladder perforation during LC.

METHODS

Between July 1997 and March 2003, 509 patients underwent LC for symptomatic gallstone disease at the Department of Surgery at Vakif Gureba Training Hospital. Data were collected retrospectively. Patients with and without gallbladder perforation were compared in terms of gender, age, anatomic difficulty, experience of the surgeon, omental and other organ adhesions to the gallbladder, and the findings of inflammation on the resected gallbladder.

RESULTS

Intraoperative gallbladder perforation occurred in 85 patients (16.6%). Although no differences were found between the perforated and nonperforated groups regarding age, gender, and chronic inflammation on the resected gallbladder, there were significant differences in terms of acute inflammation, anatomical difficulty, experience of the surgeon, and omental and organ adhesions.

CONCLUSION

Acute inflammation, degree of anatomic difficulty, the experience of the surgeon, and omental or other organ adhesions were associated with gallbladder perforation during LC.

Serum leptin levels in patients with liver cirrhosis and chronic viral hepatitis

BACKGROUND

The aim of the present study was to investigate serum leptin levels in relation to anthropometric features in patients with liver cirrhosis (LC) and chronic viral hepatitis (CVH), and to determine the effect of the severity and aetiology of the LC on serum leptin levels.

METHODS

Forty-nine patients with LC, 32 patients with CVH and 69 control subjects were age, body mass index (BMI) and sex-matched and included in the study. Plasma glucose, serum leptin and insulin levels were determined. Insulin resistance was assessed using homoeostasis model assessment (HOMA). Body composition was estimated by skinfold thickness.

RESULTS

Female patients with Child-A LC had higher levels of leptin, and female and male patients with Child-A LC had higher absolute leptin (leptin/BFM) levels compared to patients with Child-C LC and control subjects. Serum leptin levels of the patients with alcohol LC were higher than the control subjects, but the absolute leptin levels were comparable. When alcoholic and post-viral hepatitis cirrhotic patients were compared with each other on an aetiologic basis, there was no significant difference between them in leptin and absolute leptin levels. There were significant correlations between leptin and BMI, body fat percentage (BFP), BFM (body fat mass) in all three groups in both sexes.

CONCLUSIONS

These data suggest that the physiologic correlations among serum leptin level, sex, BMI and BFM were well preserved in patients with chronic liver disease. Patients with alcohol LC had higher leptin levels. In early stages of liver disease, leptin levels and absolute leptin levels are higher than in normal subjects. However, in advanced stages of the disease the significant decline in leptin levels and similar levels of leptin expressed in relation to BFM compared to control subjects predominantly represent the expression of fat mass.

Hydatid cystic disease of the soft tissues with pulmonary and hepatic involvement: report of a case

Hydatid disease, which is caused by the Echinococcus granulosis parasite, is endemic in certain parts of the world where close contact between humans and sheep exists. The disease most commonly involves the liver and other solid organs. This report describes the case of a teenage girl with hydatid disease involving the right axilla and various other sites concomitantly. The patient was admitted to hospital with a mass in the right axillary region, and further examinations revealed that the liver and right lung were also involved. We report this case to emphasize that hydatid disease should be considered in the differential diagnosis of patients from endemic areas who present with soft tissue masses.