Adult morgagni hernia: a single center experience of 5 cases and review of literature

Morgagni hernia is a rare congenital anomaly arising through the fusion defect between the septum transversum and sternum. Diagnosis is usually confusing as the presentation may be asymptomatic as well as with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness or gastrointestinal obstruction. In this paper, we discussed the clinical presentation and management of this rare situation with five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (3 laparoscopic and 2 open repair); one patient had recurrent hernia after 7 months from laparoscopic surgery. This case is the first recurrence in the literature after laparoscopic repair in an adult group. In Morgagni hernias, the only treatment is surgery, which can be performed by transthoracic, transabdominal, laparoscopic or thoracoscopic approaches. The issues of using mesh and reducing the hernia sac are still controversial.

Adult morgagni hernia: A single-center experience of five cases and a review of literature

Morgagni hernia is a rare congenital anomaly arising from the fusion defect between the septum transversum and sternum. The diagnosis is usually difficult since the presentation may be asymptomatic or with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness, or gastrointestinal obstruction. In this report, we discuss the clinical presentation and management of this rare condition in five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (three laparoscopic and two open repair surgeries); one patient developed recurrent hernia 7 months after the laparoscopic surgery. This case is the first reported recurrence in literature following laparoscopic repair in adults. Surgery is the only treatment option for Morgagni hernias, which can be performed through transthoracic, transabdominal, laparoscopic, or thoracoscopic approach. The issues of using mesh and reducing the hernial sac remain controversial.

The Effect of the Cartridge Used in Laparoscopic Sleeve Gastrectomy on the Development of a Staple-Line Leak

Morbid obesity surgery has increased by 450 per cent in the past decade. Preferred surgical techniques have also changed, and since 2014, the most common surgical procedure worldwide has been laparoscopic sleeve gastrectomy (LSG). The most serious complication of this surgery is staple-line leaks, which leads to significant increases in cost and a considerable rate of mortality. This study aimed to investigate the effects of staples used in LSG on the development of staple-line leaks. The sample of the study comprised 70 patients that consecutively underwent surgery at Dokuz Eylül University Hospital between March 2014 and June 2015. The patients were divided into two equal groups. For the first group, resection was performed using blue-green EndoGIA™ cartridges (BGC) (Medtronic, Norwalk, CT). In the other group, purple Tri-Staple™ cartridges (TSC) (Medtronic) were used. To examine the effect of the cartridge type, the point and pressure of leak was determined from fresh specimens following saline infusion. No statistically significant difference was found between the two groups in terms of mean age, body mass index, gender distribution or comorbidity. The median number of cartridges used was five in both groups. The resistance of the staple line to intragastric pressure was found to be significantly higher in the TSC group compared with the BGC group [51.94 (±18.34) mmHg and 39.77 (±17.09) mmHg, respectively, P = 0.005]. Most applications undertaken to reduce the risk of leak development in LSG aim to reinforce the staple line. There are very few studies that investigated the quality of staple line, and none examined the effect of staple cartridges on the development of leaks. Therefore, we conducted this study to fill this gap in the literature. The results revealed that tissue thickness cartridge compatibility had a role in the development of leaks during the resection of gastric tissue in which the thickness is reduced from the distal to the proximal portion. We conclude that during vertical sleeve gastrectomy, using TSC that are compatible with a wider range of tissue thickness results in more durable staple lines than EndoGIA™ cartridges.

The Effect of the Cartridge Used in Laparoscopic Sleeve Gastrectomy on the Development of a Staple-Line Leak

Morbid obesity surgery has increased by 450 per cent in the past decade. Preferred surgical techniques have also changed, and since 2014, the most common surgical procedure worldwide has been laparoscopic sleeve gastrectomy (LSG). The most serious complication of this surgery is staple-line leaks, which leads to significant increases in cost and a considerable rate of mortality. This study aimed to investigate the effects of staples used in LSG on the development of staple-line leaks. The sample of the study comprised 70 patients that consecutively underwent surgery at Dokuz Eylül University Hospital between March 2014 and June 2015. The patients were divided into two equal groups. For the first group, resection was performed using blue-green EndoGIA™ cartridges (BGC) (Medtronic, Norwalk, CT). In the other group, purple Tri-Staple™ cartridges (TSC) (Medtronic) were used. To examine the effect of the cartridge type, the point and pressure of leak was determined from fresh specimens following saline infusion. No statistically significant difference was found between the two groups in terms of mean age, body mass index, gender distribution or comorbidity. The median number of cartridges used was five in both groups. The resistance of the staple line to intragastric pressure was found to be significantly higher in the TSC group compared with the BGC group [51.94 (618.34) mmHg and 39.77 (617.09) mmHg, respectively, P = 0.005]. Most applications undertaken to reduce the risk of leak development in LSG aim to reinforce the staple line. There are very few studies that investigated the quality of staple line, and none examined the effect of staple cartridges on the development of leaks. Therefore, we conducted this study to fill this gap in the literature. The results revealed that tissue thickness cartridge compatibility had a role in the development of leaks during the resection of gastric tissue in which the thickness is reduced from the distal to the proximal portion. We conclude that during vertical sleeve gastrectomy, using TSC that are compatible with a wider range of tissue thickness results in more durable staple lines than EndoGIA™ cartridges.

The role of gamma probe activity counts in minimally invasive parathyroidectomy

Aim: The benefit of preoperative gamma probe in the diagnosis of adenoma in patients with histopathologically proven parathyroid (PT) adenomas was examined. Patients, material, methods: 20 patients with positive 99mTc MIBI uptake in PT scintigraphy with primary hyper-parathyroidism were enrolled in this study. 740 MBq 99mTc MIBI were injected 3 h before operation. Counts of four PT regions were obtained with gamma probe before surgery in the operation room. All suspected PT adenomas were resected and histopathologically diagnosed as adenomas. We also obtained counts of the resection region and the resected adenoma with gamma probe after the parathyroidectomy. Preoperative counts of adenoma bearing regions (ABR), non-adenoma bearing regions (NABR), postoperative resection region (PRR), resected adenoma counts (RA) were registered. Statistical analysis was performed by Wilcoxon rank test. Results: The mean counts of ABR, NABR, the PRR and RA were 462 ± 106, 230 ± 66, 164 ± 42, 374 ± 87, respectively. The mean counts from ABR were twofold higher than those of NABR. The PRR mean counts decreased by 64% when compared to the mean counts of ABR and by 55% when compared to the mean counts of RA. The differences in mean counts of ABR and NABR, PRR and ABR, PRR and RA (p <0.01) turned out as statistically significant. Discussion: According to our preliminary results, the region with the highest counts is at least 2 ± 0,4 times higher than the mean of the other three PT regions. Thus, it seems to be significant for PT adenoma. Resection of adenoma may be accepted as successful, if the count of ABR decreased more than 64% with decreased postoperative parathormone levels. Conclusion: This technique should not yet be applied instead of parathormone measurement or frozen technique. But it may replace the frozen technique used for confirmation of the diagnosis during the operation in the future.

Volume change of segments II and III of the liver after gastrectomy in patients with gastric cancer

PURPOSE

We aimed to evaluate the relationship between gastrectomy and the volume of liver segments II and III in patients with gastric cancer.

METHODS

Computed tomography images of 54 patients who underwent curative gastrectomy for gastric adenocarcinoma were retrospectively evaluated by two blinded observers. Volumes of the total liver and segments II and III were measured. The difference between preoperative and postoperative volume measurements was compared.

RESULTS

Total liver volumes measured by both observers in the preoperative and postoperative scans were similar (P > 0.05). High correlation was found between both observers (preoperative r=0.99; postoperative r=0.98). Total liver volumes showed a mean reduction of 13.4% after gastrectomy (P = 0.977). The mean volume of segments II and III showed similar decrease in measurements of both observers (38.4% vs. 36.4%, P = 0.363); the correlation between the observers were high (preoperative r=0.97, P < 0.001; postoperative r=0.99, P < 0.001). Volume decrease in the rest of the liver was not different between the observers (8.2% vs. 9.1%, P = 0.388). Time had poor correlation with volume change of segments II and III and the total liver for each observer (observer 1, rseg2/3=0.32, rtotal=0.13; observer 2, rseg2/3=0.37, rtotal=0.16).

CONCLUSION

Segments II and III of the liver showed significant atrophy compared with the rest of the liver and the total liver after gastrectomy. Volume reduction had poor correlation with time.

Neutrophil-to-lymphocyte ratio: could it be used in the clinic as prognostic marker for gastrointestinal stromal tumor?

BACKGROUND/AIMS

The association between systemic inflammatory response and tumor biology has been well documented over the last decade. The aim of this study is to investigate the prognostic role of neutrophilto- lymphocyte ratio (NLR) in gastrointestinal stromal tumors (GISTs).

METHODOLOGY

A prospectively recorded database of 67 patients who underwent surgical resection for GIST was reviewed. High and low NLR were defined with respect to the sample median, which was 1.92. Demographical, clinicopathological, and surgical characteristics were analyzed as well as disease free survival (DFS) rates according to NLR classification.

RESULTS

We observed better disease free survival rates in patients with low NLR compared to patients with high NLR (85.7% and 69%, respectively; p=0.037). Estimated five-year overall and disease free survival rates were 95.1% and 78.7%, respectively. In univariate analysis synchronous sarcomatosis, tumor size, mitotic rate, presence of necrosis, lymph node metastasis, surgical margin status, risk category and NLR were associated with DFS. On multivariate analysis sarcomatosis (HR: 30.455), surgical margin status (HR: 4.228) and necrosis (HR: 4.415) were found as independent prognostic factors for DFS.

CONCLUSIONS

NLR can give information about inflammatory status, tumor aggressivity and prognosis in GIST patients. It could be a new prognostic factor for GIST patients.

Tumor deposits in gastric carcinomas

We performed this study to examine the prevalence of tumor deposits (TD) in gastric adenocarcinomas (GACa), and the relevance of their presence, size and type to clinical outcome. Ninety-six patients, histopathologically diagnosed as GACa following a total/subtotal gastrectomy were included, and clinicopathologic data were recorded. Due to the statistical analysis, the majority of TD(+) cases were of intestinal type and showed vascular invasion. In these cases, the incidence of local recurrence was significantly higher. The majority of GACa of intestinal type with TD were of high grade and showed vascular invasion. Recurrence and death were more commonly encountered among them. The recurrence-free survival (RFS) was significantly shorter in patients with TDs, which was also confirmed by multivariate analysis, and there was a significant difference between both RFS and overall survival of TD(+) and TD(-) cases of intestinal type GACa. In conclusion, in this study, we demonstrate that TDs are not infrequently observed in GACa, they are more commonly associated with the intestinal type and vascular invasive gastric cancers. Our study shows the prognostic impact of TDs, especially regarding the RFS. Therefore, the documentation of TDs might be considered for prospective studies, especially for the intestinal type GACa, a shortcoming of this study.

Unusual case of severe late-onset cytomegalovirus-induced hemorrhagic cystitis and ureteritis in a renal transplant patient

Cytomegalovirus (CMV) infection is common in solid organ transplant recipients and accounts for the majority of graft compromise. Major risk factors include primary exposure to CMV infection at the time of transplantation and the use of antilymphocyte agents such as OKT3 (the monoclonal antibody muromonab-CD3) and antithymocyte globulin. It most often develops during the first 6 months after transplantation. Although current prophylactic strategies and antiviral agents have led to decreased occurrence of CMV disease in early posttransplant period, the incidence of late-onset CMV disease ranges from 2% to 7% even in the patients receiving prophylaxis with oral ganciclovir. The most common presentation of CMV disease in transplant patients is CMV pneumonitis followed by gastrointestinal disease. Hemorrhagic cystitis is a common complication following hematopoietic stem cell transplantation. The condition is usually due to cyclophosphamide-based myeloablative regimens and infectious agents. Even in these settings, CMV-induced cases occur only sporadically. Ureteritis and hemorrhagic cystitis due to CMV infection after kidney transplantation is reported very rarely on a case basis in the literature so far. We report here a case of late-onset CMV-induced hemorrhagic cystitis and ureteritis presenting with painful macroscopic hematuria and ureteral obstruction after 4 years of renal transplantation. The diagnosis is pathologically confirmed by the demonstration of immunohistochemical staining specific for CMV in a resected ureteral section. We draw attention to this very particular presentation of CMV hemorrhagic cystitis with ureteral obstruction in order to emphasize atypical presentation of tissue-invasive CMV disease far beyond the timetable for posttransplant CMV infection.

An unusual cause of small bowel perforation: apricot pit

Ingestion of foreign bodies can be a common problem, especially among children, alcoholics, and psychiatric and senile patients. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved immediately may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract uneventfully, and perforation occurs in less than 1%. In this study, we report a case of small bowel obstruction with perforation in a 73-year-old female due to the accidental swallowing of an apricot pit.

Benign solitary cecal ulcer: a condition that mimics plastron appendicitis

The benign solitary cecal ulcer is a rare clinical entity that is not usually included in the differential diagnosis of the cecal diseases. The etiology is unknown, and there are no pathognomonic lesions or symptoms. Pre-operative and intra-operative diagnosis is difficult. Definitive diagnosis is generally obtained by histologic evaluation of the surgical specimen after a right hemicolectomy performed for a suspected neoplasm of the cecum. We herein describe a 70-year-old woman with solitary cecal ulcer presenting with abdominal pain, palpable mass on the right lower quadrant and leukocytosis, mimicking plastron appendicitis on initial evaluation.

Delayed complete gastric outlet obstruction due to a dinner fork: report of a case

Ingestion of foreign bodies can be a common problem especially among children, alcoholics, psychiatric patients, and senile patients, but ingestion of a metallic dinner fork is uncommon. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved at the earliest may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract without problems, and perforation occurs in less than 1%. In this paper, a case of rare gastric outlet obstruction due to a dinner fork, which was ingested 25 days before, is reported.

What is the role of the abdominal perfusion pressure for subclinical hepatic dysfunction in laparoscopic cholecystectomy?

BACKGROUND

Subclinical hepatic dysfunction after laparoscopic cholecystectomy (LC) has been described in the literature. However, this alteration is not encountered in all patients. In order to address this situation, a prospective study was conducted to investigate the effect of abdominal perfusion pressure (APP) on liver function tests after LC performed under constant intra-abdominal pressure (IAP).

PATIENTS AND METHODS

Of 78 patients who underwent LC between May 2007 and October 2007, 40 patients were eligible for the study. In all the patients, six parameters of liver function (aspartate aminotransferase, alanine aminotransferase, direct bilirubin, indirect bilirubin, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients who showed more than a 100% increase in at least one parameter (group 1) were compared to those who did not (group 2) regarding age, sex, body weight, body height, operation time, pneumoperitoneum time, IAP, preoperative, and intraoperative APP.

RESULTS

Of the patients, 37.5% showed more than a 100% increase in at least one parameter of liver function. No significant difference was found between the two groups with regard to age, sex, body weight, body height, operation time, pneumoperitoneum time, and IAP. There were significant increase in AST and ALT at 24 hours postoperatively in group 1, as compared with group 2 (P = 0.000, P = 0.001). In comparison of preoperative APP with intraoperative APP values, group 1 showed a statistically significant decrease (P = 0.000), while no difference was found in group 2.

CONCLUSION

Subclinical hepatic dysfunction after LC could mostly be attributed to the negative effects of the pneumoperitoneum on hepatic blood flow. For the evaluation of hepatic hypoperfusion, APP may be a new criterion as a determinant of interaction with mean arterial pressure (MAP) and IAP.

Cytomegalovirus disease in renal transplant recipients: a single-center experience

Cytomegalovirus (CMV) disease is an important complication and an independent risk factor for acute rejection and recipient morbidity-mortality. The aim of this study was to review the results of CMV disease in renal transplant recipients.

METHOD

We have retrospectively analyzed CMV disease in 120 renal transplant recipients and recorded the demographic features, clinical manifestations, and immunosuppressive regimens.

RESULTS

Twenty-nine recipients (24.1%) developed CMV disease after a median interval of 2.8 +/- 2,6 months from transplantation. CMV disease developed in 36.3% of recipients who received basiliximab as induction therapy and 21.4% of recipients who were treated with anti-thymocyte globulin (ATG). The most commonly used immunosuppressive regimen was cyclosporine-A (CsA)-based (79.3%). The mean cumulative steroid dose until the diagnosis was 3,600 mg methyl prednisolone per patient. Malaise, fever, and diarrhea were the most common symptoms. Gastritis, pneumonia, and transaminitis were the most commonly seen end-organ involvements. Frequent laboratory findings were leukopenia (34.5%), increased serum creatinine level (34.5%), and leukocytosis (20.7%). We performed renal biopsy to seven patients and detected acute rejection in four patients. In 25 patients, immunosuppressive treatment was modified. Relapsing CMV disease was seen in seven patients.

CONCLUSION

In our study, CMV disease was seen in recipients who were treated with basiliximab, a finding similar to recipients who were treated with ATG.

A renal transplant recipient with delayed gastric emptying in amyloidosis due to familial Mediterranean fever improved with erythromycin: a case report

Patients with systemic amyloidosis often have symptoms related to impared gastrointestinal motility due to delayed gastric emptying, which results from autonomic nerve or smooth muscle infiltration with amyloid. There is no current report about gastric delaying secondary to amyloidosis due to familial Mediterranean fever. In this report, we have described a renal transplant recipient with delayed gastric emptying secondary to amyloidosis due to familial Mediterranean fever, which improved with erithromycin treatment.

Do MMP-1 levels of gingival fibroblasts have a role in the gingival overgrowth of cyclosporine-treated patients?

The aim of this study was to compare the matrix metalloproteinase-1 (MMP-1) levels in gingival fibroblast cultures derived from two groups of renal transplant patients receiving cyclosporine (CsA) who exhibit gingival overgrowth and who have healthy periodontium. Gingival fibroblasts obtained from four patients with CsA-induced gingival overgrowth (CsA-GO) and four patients who receive CsA but have healthy periodontium were incubated with increasing concentrations of CsA and cultured for 72 hours. Expression levels of MMP-1 in all the groups were measured four times at 0, 24, 48, and 72 hours by the Rapid Collagenase Assay Kit. No significant difference was seen at baseline. As the CsA concentration and the duration in the cell media increased, the CsA-GO showed that fibroblasts displayed significantly suppressed MMP-1 levels with respect to the baseline, at which fibroblasts from CsA patients with healthy periodontium exhibited the same result as at the highest CsA concentration. Results of this study indicated that CsA therapy did not have a significant effect on MMP-1 levels. Since the overall pathogenesis of drug-induced gingival hyperplasia has been accepted as multifactorial, down-regulation of MMP-1 expression may play a minor role.

Survivin, p53, and Ki-67 as predictors of histopathologic response in locally advanced rectal cancer treated with preoperative chemoradiotherapy

PURPOSE

The ability to predict response to chemoradiotherapy before the treatment may allow protecting poorly responding patients from the side effects of neoadjuvant treatment. Several molecular markers have been proposed to radio and chemosensitivity of rectal cancer. In this study, from pre-irradiation tumor biopsies, a novel and promising candidate factor survivin, and p53 and Ki-67 were assessed as predictors of response to preoperative chemoradiotherapy.

MATERIALS AND METHODS

Expression of each marker was evaluated by immunohistochemistry on pretreatment biopsies from 37 patients having rectal cancer treated with preoperative chemoradiotherapy and curative surgery. Treatment response was assessed histopathologically in the resected surgical specimen.

RESULTS

There was no correlation between expression of p53, Ki-67, and survivin with response to preoperative chemoradiotherapy and prognosis.

CONCLUSIONS

Our data suggest that these molecular markers are not helpful to identify patients who would have benefit from neoadjuvant treatment of rectal cancer. Further investigations are necessary to select patients for preoperative treatment based on analysis of the preoperative biopsies.

Symptomatic intestinal lipomas requiring surgical interventions secondary to ileal intussusception and colonic obstruction: report of two cases

Lipomas are rare but well-recognized tumours of the small and large intestines. They usually arise from the submucosa and may occasionally protrude into the lumen, thus causing abdominal pain resulting from obstruction or intussusception or they may become evident through haemorrhage. Intestinal lipomas should be removed either endoscopically or surgically because they can cause severe symptoms and usually a tissue diagnosis is indicated in intestinal tumours to exclude a malignancy. We describe two cases of symptomatic intestinal lipoma and review some aspects of diagnosis and treatment.

A rare clinical entity misdiagnosed as a tumor: peliosis hepatis

Peliosis hepatis (PH) is a rare condition characterized by the presence of cystic, blood filled cavities within the hepatic parenchyma. Regardless of the reason, surgery should be performed under meticulous control of hemorrhage, if it is thought to be unavoidable. In this case report, ominous results of clinically misdiagnosed PH have been presented. PH should be kept on mind in all patients with hepatic mass, especially presented by sudden onset distention of the abdomen. Every effort should be done for the differential diagnosis with other cystic conditions like hydatid cyst in endemic areas.

The role of gamma probe activity counts in minimally invasive parathyroidectomy. Preliminary results

AIM

The benefit of preoperative gamma probe in the diagnosis of adenoma in patients with histopathologically proven parathyroid (PT) adenomas was examined.

PATIENTS, MATERIAL, METHODS

20 patients with positive (99m)Tc MIBI uptake in PT scintigraphy with primary hyperparathyroidism were enrolled in this study. 740 MBq (99m)Tc MIBI were injected 3 h before operation. Counts of four PT regions were obtained with gamma probe before surgery in the operation room. All suspected PT adenomas were resected and histopathologically diagnosed as adenomas. We also obtained counts of the resection region and the resected adenoma with gamma probe after the parathyroidectomy. Preoperative counts of adenoma bearing regions (ABR), non-adenoma bearing regions (NABR), postoperative resection region (PRR), resected adenoma counts (RA) were registered. Statistical analysis was performed by Wilcoxon rank test.

RESULTS

The mean counts of ABR, NABR, the PRR and RA were 462 +/- 106, 230 +/- 66, 164 +/- 42, 374 +/- 87, respectively. The mean counts from ABR were twofold higher than those of NABR. The PRR mean counts decreased by 64% when compared to the mean counts of ABR and by 55% when compared to the mean counts of RA. The differences in mean counts of ABR and NABR, PRR and ABR, PRR and RA (p <0.01) turned out as statistically significant.

DISCUSSION

According to our preliminary results, the region with the highest counts is at least 2 +/- 0,4 times higher than the mean of the other three PT regions. Thus, it seems to be significant for PT adenoma. Resection of adenoma may be accepted as successful, if the count of ABR decreased more than 64% with decreased postoperative parathormone levels.

CONCLUSION

This technique should not yet be applied instead of parathormone measurement or frozen technique. But it may replace the frozen technique used for confirmation of the diagnosis during the operation in the future.

[Rectal foreign bodies: a report of four cases]

Foreign bodies were detected in the rectum in four male patients with ages ranging from 36 to 64 years. The materials were an iron rod, a specially shaped wooden device, and in two cases, deodorant caps. They were extracted with the patients in lithotomy position after anal dilatation, under general anesthesia in three cases, and spinal anesthesia in one case. No procedure-related complications occurred and the patients were discharged 24 hours after the operation.

[The beneficial effect of L-carnitine in rat renal ischemia-reperfusion injury]

BACKGROUND

We examined the effect of L-carnitine on experimental renal ischemia-reperfusion (I-R) injury.

METHODS

Seventy-two Wistar albino rats were divided into five groups, four of which underwent right nephrectomy and left renal I-R for 60 min (groups 2 and 4) and 90 min (groups 3 and 5). The sham operated group (n=8) was left as controls. Intraperitoneal carnitine (200 mg/kg) was given to groups 4 and 5 three hours before operation. For histopathologic studies, half of the rats in the study groups (n=8) and the remaining rats were sacrificed 15 min and seven days after reperfusion, respectively. Blood urea nitrogen (BUN) and serum creatinine levels were also measured at 15 min and on Day 3 and Day 7.

RESULTS

Concerning the 90 min I-R groups, survival was improved in carnitine-treated rats (7/8 vs 5/8). Of untreated groups, the 90 min I-R group exhibited significantly higher BUN (p=0.0023) and serum creatinine (p=0.0086) levels on Day 3. Although BUN and serum creatinine levels did not show significant differences between carnitine-treated and untreated rats in the two 60 min I-R groups throughout the study period, carnitine-treated rats in the 90 min I-R group exhibited significantly improved BUN (p=0.0063) and serum creatinine (p=0.0013) levels on Day 3. The severity of histopathologic changes was lower in all carnitine-treated rats 15 min after reperfusion. On Day 7, the mean histopathologic score was significantly lower in carnitine-treated rats in the 90 min I-R group than that of untreated rats exposed to I-R injury of same duration (p=0.0078).

CONCLUSION

Our results suggest that L-carnitine has beneficial effects on renal function, histopathologic changes, and survival in renal ischemia-reperfusion injury.

The effects of vascular bed expansion in steatotic rat liver graft viability

Disturbed microcirculation caused by fat accumulation in hepatocytes has been implicated in poor graft preservation and reperfusion. The aim of this study was to investigate the effect of vascular bed expansion (VBE) during cold preservation in graft survival Moderate liver steatosis in male Wistar rats (240-280 g) was induced by choline-deficient diet. Normal, steatotic or VBE-pretreated steatotic grafts were transplanted after 1 h or 9 h of cold preservation. Graft viability was determined by 7-day survival, serum liver enzymes, plasma tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, and malondialdehyde (MDA) levels. Post-reperfusion bile flow and liver histology were also examined. After 9 h of preservation, VBE-pretreated steatotic liver grafts were associated with significantly reduced serum liver enzyme, plasma TNF-alpha, IL-6, and MDA levels, as well as increased bile flow and higher survival rates compared with untreated ones. The present study shows that VBE protects fatty liver grafts from subsequent long-term cold preservation and reperfusion injury in a rat liver transplantation model.

Spigelian hernia associated with strangulation of the small bowel and appendix

Spigelian hernia is a rare lateral ventral abdominal hernia. These clinically elusive hernias are treacherous and have a real risk of strangulation. We present a patient with a strangulation of the small bowel and appendix in a right spigelian hernia, which was accurately demonstrated by spiral computerised tomography preoperatively and successfully treated with primary suturing reinforced with polypropylene mesh. With a high index of suspicion and the use of modern radiological technique, these "bewildering" hernias can be diagnosed and repaired relatively safely.

Incarcerated inferior lumbar (Petit's) hernia

Petit's hernia is an uncommon abdominal wall defect in the inferior lumbar triangle. Colonic incarceration through the inferior lumbar triangle, which causes mechanical obstructive symptoms, necessitates particular diagnostic and management strategy. We present a rare case of inferior lumbar hernia, leading to mechanical bowel obstruction, successfully treated with prosthetic mesh reinforcement repair.

Evaluation of prosthetic mesh closure in semiopen-abdomen patients

BACKGROUND

To avoid the adverse consequences of abdominal compartment syndrome and to reduce the high mortality the celiotomy wound in patients with abdominal sepsis was closed without tension using prosthetic mesh. This produces a semiopen situation that permits staged reinterventions together with the functional reconstitution of the continuity of the abdominal wall.

MATERIAL AND METHODS

Twenty-five patients with intra-abdominal sepsis of various causes were evaluated retrospectively to assess the results of semiopen management of the septic abdomen and reoperations on demand in severe peritonitis. All of the patients were in a state of neglected peritonitis, and had at least one failing organ system. The Mannheim Peritonitis Index (MPI) scoring system was used for stratification of abdominal sepsis.

RESULTS

The mean MPI score of 25 patients was 24, ranging 10 to 33. Eight (32%) patients were reexplored (MPI=21). There were overall 9 (36%) complications in patients with mean MPI score of 23. Six (24%) mesh-related complications (infection and enterocutaneous fistulas) developed (MPI=19). The mean MPI score of patients without complications was 24. Four (16%) patients died with index MPI score of 26 due to fulminant hepatitis, myocardial infarction, and multiple organ failure. The admission period averaged 63 days.

CONCLUSIONS

In 25 critically ill patients with abdominal sepsis the mortality was lower than expected, relative to heterogeneous data from the literature; also, major complications occurred less frequently although the mean MPI score was high. The authors conclude that this approach is a reliable contribution to the complex treatment of these patients.

Protective effects of carnitine in an experimental ischemia-reperfusion injury

BACKGROUND/AIMS

We aimed to determine the role of exogenous carnitine to prevent ischemia-reperfusion damage in liver tissue in experimental model.

METHODS

Rats were divided into four groups as Sham (SG), 30% Hepatectomy (HG), ischemia-reperfusion +30% hepatectomy (IRHG) and ischemia-reperfusion+30% hepatectomy+carnitine (IRHCG). Serum AST, ALT and GGT levels have been determined in systemic blood samples (post-hepatic vena cava) and liver tissue and serum carnitine levels in blood samples from portal vein (pre-hepatic blood samples).

RESULTS

Serum carnitine levels were significantly higher in IRHCG compared to SG (P < 0.01). Each of the serum AST, ALT and GGT levels were statistically higher in HG, IRHG and IRHCG than SG (P < 0.001). While these values in IRHG were also higher than those in HG (P < 0.001), in IRHCG enzyme levels were significantly lower than IRHG (P < 0.001). Liver tissue damage was less in IRHCG than IRHG statistically (P < 0.001).

CONCLUSIONS

This animal model implies that exogenous carnitine supplementation may be helpful in preventing free oxygen radical damage and inflammatory reactions in liver tissue.

[Acute appendicitis in pregnancy]

BACKGROUND

Review of our cases of appendicitis with pregnancy.

METHODS

Between june 1990 and may 2001, eighteen cases were investigated, retrospectively.

RESULTS

Six patients were in first trimester, 10 in second trimester and 2 in third trimester. Mean age was 25. Sixteen cases (88.9%) were acute appendicitis and 2 cases (11.1%) were perforated appendicitis. The time interval between the onset of complaints and operation was 1.6 days. There were no fetal or maternal mortality. One of perforated appendicitis developed wound infection and two developed atelectasis.

CONCLUSION

Early laparotomy in appendicitis with pregnancy will reduce the fetal and maternal morbidity and mortality.

Mirizzi's syndrome: diagnostic and surgical considerations in 25 patients

Mirizzi's syndrome is a rare complication of long-standing cholelithiasis. Many surgical approaches of varying complexity have been advocated for treatment. However, the distorted extrahepatic biliary anatomy continues to be threatening, with a high risk of biliary complications. Presented here is a series of 25 patients with Mirizzi's syndrome who were treated at the Dokuz Eylul University Hospital since 1985. Type I lesion (without cholecystocholedochal fistula) was encountered in 11 patients, while the remaining 14 had type II lesions (with cholecystocholedochal fistula). Preoperative diagnoses were made in 14 of the 25 patients (56%). Follow-up in 17 patients ranged from 1 to 96 months (mean, 40 months). Unfortunately, the remaining 8 patients were lost to follow-up after discharge. The morbidity rate in our series was 32%, while no mortality was encountered. During long-term follow-up, no biliary stricture was diagnosed. Following an uneventful postoperative course, all of our patients are symptom-free and doing well, with normal liver function. We conclude that partial cholecystectomy alone is a safe and sound surgical approach for the treatment of type I lesions. For type II lesions, depending on the size of the fistula, either primary closure over a T-tube, or bilio-digestive anastomosis, preferably Roux-en-Y, can be an appropriate treatment modality, with a low morbidity rate.