Management of wet ascitic type of peritoneal tuberculosis: single center experience

OBJECTIVE

We aimed to present our experience with the management of 17 patients with ascites who underwent diagnostic laparoscopy or laparotomy, and histologic confirmation of wet ascitic type of peritoneal tuberculosis (TB).

PATIENTS AND METHODS

Between January 2008 and March 2019, 17 patients whose ascites were investigated by a gastroenterologist and who were thought to have non-cirrhotic ascites were referred to our Surgery clinic for peritoneal biopsy. The clinical, biochemical, radiological, microbiological, and histopathological data of the patients who underwent diagnostic laparoscopy or laparotomy were analyzed retrospectively. Histopathological examination of peritoneal tissue samples in hematoxylin-eosin-stained preparations revealed necrotizing granulomatous inflammation with caseous necrosis and Langhans type giant cells. Ehrlich-Ziehl-Neelsen (EZN) staining was studied with the suspicion of TB. Acid-fast bacilli (AFB) were detected in EZN stained slide. Histopathological findings were also considered.

RESULTS

Seventeen patients aged 18 to 64 years were included in this study. The most common symptoms were ascites and abdominal distention, weight loss, night sweats, fever and diarrhea. Radiological examination revealed peritoneal thickening, ascites, omental cacking, and diffuse lymphadenopathy. Histopathologically, necrotizing granulomatous peritonitis consistent with peritoneal TB were detected. While direct laparoscopy was preferred in sixteen patients, laparotomy was preferred in the remaining one due to previous surgical procedures.  However, seven were converted to open laparotomy.

CONCLUSIONS

Diagnosis of abdominal TB requires high index of suspicion, and the treatment should be prompt to reduce the morbidity and mortality associated with delay in treatment.

Ectopic bone formation in thyroid gland: report of sixteen cases and comprehensive literature review

OBJECTIVE

This study aimed to analyze the outcomes of patients with ectopic bone formation (EBF) diagnosed in thyroidectomy specimen.

PATIENTS AND METHODS

We retrospectively analyzed the data of 16 patients who underwent thyroidectomy between February 2009 and June 2018 and whose pathology examination diagnosed EBF.

RESULTS

Fourteen patients underwent bilateral total thyroidectomy (BTT), one patient required BTT with central lymph node dissection, and one patient was subjected to BTT with functional lymph node dissection. On histopathological examination, left lobe EBF was diagnosed in four patients; left lobe EBF with bilateral papillary thyroid carcinoma (PTC) in two; left lobe EBF with left lobe PTC in one; left lobe EBF with left follicular adenoma in one; left lobe EBF with right lobe papillary thyroid microcarcinoma in one; bilateral EBF in one; right lobe EBF with extramedullary hematopoiesis in one; right lobe EBF in three; right lobe EBF with right lobe medullary thyroid carcinoma in one, and right lobe EBF with bilateral lymphocytic thyroiditis in one. One of the five patients who underwent bone marrow biopsy was diagnosed with myeloproliferative dysplasia, and another with polycythemia vera. Three patients were treated medically for anemia because no other pathological findings could be observed.

CONCLUSIONS

There is a lack of literature data about the clinical significance of EBF in the thyroid gland in cases with no concomitant hematological diseases. People who have been diagnosed with EBF in the thyroid gland should be checked for hematological diseases.

Effect of ursodeoxycholic acid on liver regeneration capacity after living donor hepatectomy: a prospective, randomized, double-blind clinical trial

OBJECTIVE

Ursodeoxycholic acid (UDCA) has multiple hepatoprotective activities: it modifies the bile acid pool, decreases levels of endogenous, hydrophobic bile acids while increasing the proportion of nontoxic hydrophilic bile acids. It also has cytoprotective, antiapoptotic, and immunomodulatory properties. The aim of this study was to analyze the effect of postoperative administration of UDCA on liver regeneration capacity.

PATIENTS AND METHODS

This is a single-center, prospective, randomized, double-blind study that was carried out in our Liver transplant Institute. Sixty living liver donors (LLDs) who underwent right lobe living donor hepatectomy were divided into two groups using computer-generated random numbers: one group received oral UDCA 500 mg 12 hourly for 7 days (UDCA group; n=30) from the first postoperative day (POD) and the other did not receive UDCA (non-UDCA group; n=30). Both groups were compared in terms of the following parameters: clinical and demographic parameters, liver enzymes (ALT, AST, ALP, GGT, total bilirubin, direct Bilirubin), and INR.

RESULTS

The median ages in the UDCA and non-UDCA were 31 years (95% CI for median: 26-38) and 24 years (95% CI for median: 23-29), respectively. Liver function tests showed significant differences at various times within the first seven PODs. The INR was lower in UDCA group patients on POD3 and POD4. However, GGT was significantly lower on POD6 and POD7 for the UDCA group. Total bilirubin was also significantly lower on POD3 for the UDCA group patients, but ALP was lower all from POD1 to POD7. A significant difference was also observed in AST on POD3, POD5 and POD6.

CONCLUSIONS

Postoperative administration of oral UDCA significantly improves liver function tests and INR among LLDs.

Factors affecting anxiety, depression, and stress among patients with hepatocellular carcinoma during COVID-19 pandemic

OBJECTIVE

Patients with chronic disease whose treatments are limited may experience depression, anxiety, and stress-related symptoms, as well as an increase in the levels of these conditions. This study aims to determine the factors affecting the depression, stress, and anxiety levels of hepatocellular carcinoma (HCC) patients due to the fear of COVID-19 exposure.

PATIENTS AND METHODS

118 patients with advanced HCC treated with non-transplant treatment options or on the waiting list due to the lack of a donor were enrolled. To evaluate the stress, depression, and anxiety levels during the COVID-19 process, Depression Anxiety Stress Scales (DASS-21) and the Coronavirus Anxiety Scale (CAS) were administered to 118 patients through a face-to-face interview. Sociodemographic and clinical characteristics were recorded, and the primary endpoint measure was the total score of DASS. In addition, the multilayer perceptron (MLP) model was constructed to predict the scores of the DASS-21 total.

RESULTS

There were significant differences between DASS depression (p=0.010; p=0.030) DASS anxiety (p=0.010; p=0.010) and DASS total (p=0.046; p=0.023) scores in terms of gender and protective effect of the vaccine. Also, a significant difference between gender for the CAS scale was determined (p=0.044). The median score of the DASS total in the COVID-19 group was higher than in the non-COVID-19 group; however, the increase was not significant. MLP model revealed that chronic disease, gender, age, place of residence, smoking, type of vaccine, and COVID-19 exposure were the most important predictors for the DASS total.

CONCLUSIONS

Chronic disease, gender, and age were prominent factors in predicting the DASS-21 total score in HCC patients. Therefore, the crucial factors were clinically considered for managing depression, stress, and anxiety in HCC patients.

Vessel sealing system vs. conventional knot-tying for hilar dissection during living donor hepatectomy: a prospective, randomized, double-blinded study

OBJECTIVE

LT has become the gold standard treatment for many liver diseases, especially chronic liver disease. A commonly seen problem, even in donors who do not develop any major complications after living donor hepatectomy (LDH), is the persistent drainage of lymphatic fluid from the hepatectomy site drain, which causes extensive hospitalization and consequent loss to the workforce. To our knowledge, no study has yet been published comparing LVSS and conventional knot-tying methods for hilar dissection, which is an important stage of the LDH procedure. We aimed to prospectively compare the outcomes of these two treatment methods.

PATIENTS AND METHODS

Donor candidates were divided into two groups: conventional suture tying (conventional knot tying group; n=34) and Ligasure vessel sealing system (LVSS; n=34). A simple randomization method of drawing lots was used to assign the patients to each group. The following parameters were analyzed for all patients: age, gender, BMI, duration of surgery, postoperative drainage amounts, drain removal times and complications, length of hospital stay, morbidity, and mortality.

RESULTS

There were no significant differences in terms of operative times, postoperative drainage levels, hospital stay or drain removal times.

CONCLUSIONS

In this study, the use of LVSS in LDH was found to be safe, although it did not offer any advantage over conventional methods. Nevertheless, it seems probable that the use of LVSS could reduce operative time and amounts of lymphatic drainage, especially in centers with minimal experience with LDH, such as new LDH centers.

Hepatitis B/D-Related Hepatocellular Carcinoma. A Clinical Literature Review

AIM

Given the current literature data, this article aims to shed light on the epidemiological and clinical effects of HBV, as well as its impact on the development of hepatocellular carcinoma (HCC).

METHODS

A review of the English language literature based on a MEDLINE (PubMed) database was searched. The keywords were cirrhosis, hepatocellular carcinoma, epidemiology, hepatitis delta virus, hepatitis B virus, and co-infection. All references from retrieved papers were reviewed systematically to find additional collection of reports.

RESULTS

The study has broadly confirmed the contribution of HDV viremia to liver disease and cirrhosis. However, uncertainty over the mechanism of action on HCC development remains. As the recent data has demonstrated, the HCC-HDV has a unique molecular profile which is distinct from that of HBV-HCC.

CONCLUSION

Owing to the dependence of HDV on HBV, it is not clear whether HCC is a consequence of the cumulative effect of both HBV and HDV, an effect of the underlying cirrhosis, or a direct oncogenic effect of HDV. Many questions concerning the oncogenic role of HDV remain unanswered. To better understand the role of HDV in carcinogenesis, studies at the molecular level that consider genotype differences should be increased. Multicenter, high-volume, and prospective studies that compare HBV/HDV co-infected and HBV-infected individuals will be pivotal in determining the oncogenic role of HDV.

Aborted donor hepatectomy in living donor liver transplantation: lessons learned

BACKGROUND

Aborted donor hepatectomy (ADH) during any stage of living donor hepatectomy (LDH) is a rare event. We describe our experience and discuss the lessons from these events.

METHODS

From September 2005 to January 2019, 77 of 2 031 (3.79%) LDH were aborted at various stages of surgical procedure due to donor or recipient related reasons. Demographic and clinical data of aborted donor candidates and the clinical course of their potential recipients were analysed.

RESULTS

LDH of 77 donor candidates was aborted due to donor (n = 53) or recipient (n = 24) related reasons. The most common donor related reason was the quality of liver parenchyma (n = 31). The most common recipient related reason was haemodynamic instability (n = 11). Twenty-three recipients underwent either living donor liver transplantation (LDLT) (n = 21) or deceased donor liver transplantation (DDLT) (n = 2) at a median of 6 days following ADH. In one aborted due to a donor reason and two aborted for recipient reasons, LDLT was performed using the same donor candidates. Thirty-six recipients had no liver transplantation (LT) and died a median of 17.5 days following ADH.

CONCLUSIONS

We believe that ADH will decrease with experience and meticulous preoperative clinical and radiological evaluations. Abandoning the donor hepatectomy is always a valid option at any stage of the surgery when the unexpected is encountered.

Salivary gland anlage tumour of the nasopharynx: A case report and review for histopathological characteristics

INTRODUCTION

Congenital salivary gland anlage tumour of the nasopharynx is a lesion which usually presents with nasal and upper respiratory tract obstruction in the neonatal period. Timely diagnosis is essential to prevent the occurrence of respiratory complications in later childhood.

CASE REPORT

We present a 8-year-old boy complaining from difficulty in breathing and breastfeeding in the neonatal period due to an adenoid-like nasopharyngeal mass. Histological examination revealed solid and cystic squamous nests and numerous duct-like structures within collagenised stroma. Both epithelial and myoepithelial differentiation were noted in the tubular component.

DISCUSSION

A review of the clinical and histopathological features of published cases revealed that ancient lesions showed more prominent and complex epithelial component and more collagen rich stroma. We would like to suggest the possibility of salivary gland anlage tumour to be considered in the differential diagnosis of neonatal respiratory distress cases.

Effect of a honey and arginine-glutamine-hydroxymethylbutyrate mixture on the healing of colon anastomosis in rats immunosuppressed with tacrolimus

We compared the effect of honey and a mixture of arginine-glutamine-hydroxymethylbutyrate (AGHMB) on healing of a descending colon anastomosis in rats that were immunosuppressed with tacrolimus (Tac). Sprague-Dawley rats were divided into four groups: untreated control, Tac, Tac + honey and Tac + AGHMB. Colon resection and anastomosis were performed on day 14 and re-laparotomy was performed on the day 21 of the study. Anastomotic bursting pressure, macroscopic adhesion score, weekly body weight changes, histopathological features and immunohistochemical staining of TGF-β1 were determined for all groups. We found no significant difference in anastomotic bursting pressure among the experimental groups. We found significant weekly increases in body weight for the Tac + honey group. We found no significant difference in the weekly body weight measurements for the Tac + AGHMB group. We found significant increases in TGF-β1 expression in the Tac + honey group compared to the control and Tac groups. No significant differences in inflammatory cell infiltration, fibroblast proliferation or collagen deposition were found between the Tac + honey and Tac + AGHMB groups; however, a significant difference in neovascularization between these groups was found. Neovascularization in the Tac + honey group was significantly greater than for the Tac + AGHMB group. We found that both honey and the AGHMB mixture were beneficial for anastomotic wound healing in rats that were immunosuppressed using Tac.

Is there any relationship between clinical parameters and histopathologic features of gallbladder specimens obtained from living liver donors?

OBJECTIVE

To investigate whether there is any relationship between the clinical parameters and the histopathological features of the gallbladder (GB) specimens obtained from living liver donors (LLDs).

METHODS

The demographic (age, sex, height, weight, and BMI), clinical (liver graft type, liver graft weight, and GB volume), microbiological (bile culture), and histopathological (width, length, wall thickness, and microscopic properties of the GB specimen) data of 169 LLDs, who underwent living donor hepatectomy between October 2015 and October 2017, were prospectively recorded and retrospectively analyzed. The LLDs were compared with respect to sex (male vs. female) and the histopathological features of the GB (normal structure vs. chronic cholecystitis vs. cholesterolosis/polyps/cholelithiasis).

RESULTS

There were no significant differences between both sexes with respect to age, graft type, and some features of GB (volume, wall thickness, width, length, and bile culture). On one hand, there were significant differences between both sexes with regard to height (P < 0.001), weight (P < 0.001), BMI (P < 0.001), histopathological findings (P = 0.003), and graft size (P = 0.003). Comparison with regard to GB's histopathological features revealed no significant differences between the three groups with respect to age, weight, and some features of GB (volume, length, width, and bile culture). On the other hand, the three groups were significantly different in terms of sex (P = 0.003), height (P = 0.008), BMI (P = 0.002), and wall thickness (P = 0.044). Bile culture proliferation occurred in none of the patients except for one patient.

CONCLUSION

This study is the first to assess GB's volume, dimensions, and bile culture in healthy individuals such as LLDs.

Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation

AIM

Hepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation.

METHODS

A total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined.

RESULTS

Nine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive.

CONCLUSION

The factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.

The effect of peritoneal dialysis with alkaline dialysate in peritonitis carcinomatosis: an experimental study in mice

OBJECTIVE

The aim of this study was to neutralize acidic pH using an alkaline dialysate for continuous ambulatory peritoneal dialysis (CAPD) in mice with peritoneal carcinomatosis (PC) and to investigate the change of the pH level in the acidic fluid along with its effects on liver oxidative stress, liver and kidney histopathology and the lifespan of the body.

MATERIALS AND METHODS

A total of 38 mice were randomly divided into 4 groups.PC development was inhibited by intraperitoneal injection of Ehrlich tumor cells in all mice in each group.

RESULTS

In the group-1 receiving CAPD, the pH levels of acidic liquid were higher; and the levels of liver TBARS were lower with higher reduced glutathione levels. Histopathological damage in group-1 was less than in group-2. In Group 3 receiving CAPD, the average lifespan extended by 10.4%. The average lifespan extended by 26.1%.

CONCLUSION

This study indicated that applying CAPD with alkaline dialysate in PC contributed to the neutralization of acidosis of the intraperitoneal acid structure;had favorable effects on oxidative stress markers in liver tissue; prevented histopathological injury in liver and kidney tissues, and extended the life span of the body in mice. As this is a simple, inexpensive, and easily available method, larger studies are warranted to evaluate its effects.

Massive Subcutaneous Emphysema, Pneumoperitoneum, Pneumoretroperitoneum, and Pneumoscrotum following Endoscopic Retrograde Cholangiopancreatography in a Living Liver Donor

Despite having many advantages, living donor liver transplantation has not been adopted by western countries due to risk of nearly life-threatening complications after living donor hepatectomy (LDH). Herein, we aimed at presenting the management of a 19-year-old patient who suffered life-threatening complications after right lobe LDH. A multiple detector computed tomography (MDCT) revealed a bilioma at the cut surface of the remnant liver, for which a transhepatic drainage catheter was placed. Endoscopic retrograde cholangiopancreatography (ERCP) performed to decompress biliary tract, but the biliary tract could not be cannulized due to post-precut bleeding. On the next day, extensive crepitation was detected and MDCT showed subcutaneous emphysema, pneumoperitoneum, pneumoretroperitoneum, and pneumoscrotum (ERCP-related duodenal perforation?). However, the patient showed significant deterioration of physical examination findings, fever, and infectious parameters, and therefore was taken to the operating room. Kocher maneuver revealed no apparent duodenal perforation. Then, a 2-mm bile duct was found open at the caudate lobe, through which bile leaked. Then, common bile duct exploration and T-tube placement were performed, followed by suture closure of the bile orifice at the caudate lobe. Massive air previously identified completely disappeared one week after the operation.

Laparoscopic management of hydatid cyst of the liver

BACKGROUND

Hydatid liver disease management has evolved from traditional operative approaches to the increasing application of laparoscopic treatments. We aimed to prospectively assess the early outcomes of laparoscopic treatment at our institution.

PATIENTS AND METHODS

Forty-four patients with hydatid disease of liver were screened with ultrasonography and computed tomography of the abdomen to exclude Gharbi type V cysts. The distribution of cyst sizes was: 1-4 cm, 10; 5-10 cm, 24; 10-15 cm, 8; > 15 cm, 2 patients. The following laparoscopy therapies were performed: 30 patients had cystectomy alone, 14 patients had partial pericystectomy. Pericystectomy was performed using a hook and harmonic tissue sealers with the resection made through normal liver tissue.

RESULTS

Three patients were converted to open surgery. Seven patients had biliary leakage through their cystic cavity drains. Five stopped spontaneously by the 7th postoperative day and 2 responded to ERCP sphincterotomy. There were no deaths and no recurrence of disease noted by 6 months.

CONCLUSION

In selected patients with hepatic hydatid disease, a laparoscopic treatment is feasible and safe with low conversion rate and short term recurrences.

Circumferential Fence With the Use of Polyethylene Terephthalate (Dacron) Vascular Graft for All-in-One Hepatic Venous Reconstruction in Right-Lobe Living-Donor Liver Transplantation

Integration of hepatic vein tributaries with a diameter ≥ 5 mm into the drainage system in right-lobe living-donor liver transplantation (LDLT) is of vital importance for graft function. Recently, the most commonly emphasized hepatic venous reconstruction model is the all-in-one reconstruction model. In the final stage of this model that aims to form a common large opening, allogeneic vascular grafts are almost always used to construct a circumferential fence. To date, no other study has reported the use of polyethylene terephthalate (Dacron) vascular graft as a circumferential fence in LDLT. We aimed to present the 1st 4 cases of circumferential fences created with Dacron vascular graft. Four right-lobe grafts weighing 522-1,040 g were used. A polytetrafluoroethylene vascular graft was used for the integration of segment 5 vein and segment 8 vein into the drainage model, whereas a Dacron graft was used to creating a circumferential fence. The patency of hepatic outflow evaluated with the use of multidetector computerized tomography at postoperative day 7. Venous outflow obstruction was not detected in any cases. This study suggested that owing to its flexible structure the polyethylene terephthalate vascular graft can be an alternative to allogeneic vascular grafts in forming circumferential fence.

Histopathologic Findings of Cholecystectomy Specimens in Patients Who Underwent Donor Hepatectomy for Living Donor Liver Transplantation

BACKGROUND

The aim of this study was to discuss the macroscopic and microscopic properties of gallbladder specimens obtained from living liver donors.

METHODS

The study retrospectively analyzed the clinical and histopathological data of 1088 donors who underwent living donor hepatectomy between March 2005 and September 2014 at Inonu University Faculty of Medicine, Liver Transplantation Center. Age, sex, macroscopic, and microscopic properties of the gallbladder (bladder length, diameter, content, and histopathological properties) were recorded by 2 researchers.

RESULTS

A total of 1009 donors aged 17 to 66 years (31.1 ± 9.5) met the inclusion criteria, whereas 79 donors were excluded due to missing data. In total, 587 donors were male (30.5 ± 9.1 years [16-63 years]) and 422 were female (31.8 ± 9.8 years [18-66 years]). Preoperative tests revealed Gilbert syndrome in 3 subjects, whereas other donors' biochemical tests were within normal ranges. The macroscopic examination of gallbladders revealed mean gallbladder wall thickness, length, and width of 1.82 ± 0.8 mm (1-10 mm), 72 ± 11.4 mm (40-120 mm), and 52.5 ± 14 mm (15-90 mm), respectively. The microscopic gallbladder examination showed that 740 donors had a normal gallbladder, 193 had chronic cholecystitis (1 donor had antral metaplasia and 1 had intestinal metaplasia), 40 had cholesterolosis (1 donor had both tubular adenoma and intestinal metaplasia), 15 had minimal chronic cholecystitis (1 donor had pyloric metaplasia), 14 had cholelithiasis, 2 had adenomyosis, 2 had muscular hypertrophy, 1 had papillary hyperplasia, 1 had microdiverticulitis, and 1 had mucosal lymphatic ectasia.

CONCLUSION

The results of this study reflect the actual gallbladder pathologies that can be detected in healthy people. Clearer conclusions can be reached about the epidemiological data on gallbladder as the number of living liver donors increases in the future.

Postoperative Pulmonary Complications After Liver Transplantation: Assessment of Risk Factors for Mortality

BACKGROUND

The aim of this study was to identify the risk factors related to mortality in liver transplant (LT) patients with post-transplantation pulmonary complications.

METHOD

Patients who underwent liver transplantation in our clinic between January 2010 and January 2012 were retrospectively reviewed for post-transplantation pulmonary complications. Demographic, clinical, radiologic, and postoperative chart data of 153 patients with pulmonary complications were analyzed using an independent samples Student t test, Pearson's χ(2) test, Fisher's exact test, and Yate's corrected χ(2) test. Mortality was analyzed using a multiple logistic regression model. The best-fit breakpoint resulting in a cut-off value for the variables of interest was determined using ROC curves and the Youden index.

RESULTS

The 153 patients with pulmonary complication were divided into 2 groups: mortality (n = 53) and survival (n = 100). Univariate analyses showed significant differences between these 2 groups with respect to MELD score (P = .035), duration of mechanical ventilation (P > .001), pneumonia (P = .01), and endotracheal culture results (P = .001). In the multivariate analysis, hemoglobin (P = .03, odds ratio [OR]: 1.239), MELD score (P = .027, OR: 1.064), duration of mechanical ventilation (P = .003, OR: 1.091), and age (P = .042, OR: 1.001) were significant risk factors for mortality. The best-fit breakpoint analysis yielded cut-off values for hemoglobin (>11.2, sensitivity: 50.9%, specificity: 70%), MELD score (>16, sensitivity: 73.6%, specificity: 42%) and duration of mechanical ventilation (>3, sensitivity: 62.3%, specificity: 76%).

CONCLUSION

Advanced age, high hemoglobin level, high MELD score, and long-term mechanical ventilation are significant risk factors for mortality in liver transplant patients with postoperative pulmonary complications.

The effect of different suture materials on the safety of colon anastomosis in an experimental peritonitis model

BACKGROUND

The aim of this experimental study was to compare the safety of different suture materials in a left colonic anastomosis in the presence of peritonitis.

MATERIALS AND METHODS

Twenty-one male Wistar albino rats were randomly divided into three groups. First, left colonic injuries were created in all groups for the peritonitis model. After 24 hours, coated polyglactin 910 and silk suture were used in Group I rats, polydioxanone and silk suture were used in Group II rats, and coated polyglactin 910 plus antibacterial suture and silk suture were used in Group III rats during colonic anastomosis. Tissue hydroxyproline, anastomotic bursting pressure, and histopathologic findings on the anastomosis line were evaluated on the 10th postoperative day by performing a relaparatomy.

RESULTS

The mean bursting pressure values were 198 ± 11.37, 220 ± 17.7, and 244 ± 9.52 in Groups I, II, and III, respectively (Group I vs. II, p < 0.035; I vs III, p < 0.002; and II vs III, p < 0.021). The mean hydroxyproline levels were 1.21 ± 0.58, 1.47 ± 0.44, and 2.11 ± 0.32 in Groups I, II, and III, respectively (Group I vs II, p < 0.338; I vs III, p < 0.011; and II vs III, p < 0.025). When histopathologic findings of the groups were compared, the healing score of the intestinal tissue was higher in Group III than in Group I (p < 0.015), whereas there were no statistically significant differences among Groups I vs II and II vs III (p < 0.081 and p < 0.095, respectively).

CONCLUSION

Antibacterial suture usage increased anastomosis safety in the presence of peritonitis in resection and primary anastomosis.

Unusual cause of defecation disturbance: a presacral tailgut cyst

BACKGROUND

The aim of this study was to provide an overview of the literature on Tailgut cysts (TGCs) arising in the presacral space.

MATERIALS AND METHODS

We present a new case of presacral TGC and a literature review of English-language studies of presacral TGCs, accessed through the PubMed and Google Scholar databases. Keywords used were presacral or retrorectal tailgut cyst, presacral mucus-secreting cyst, retrorectal cystic hamartoma, retrorectal tumor, vestigial retrorectal or presacral cyst, and presacral cystic tumor.

RESULTS

A 29-year-old woman presented to our Clinic with defecation disturbance caused by a presacral TGC. Our literature review resulted in the inclusion of 94/111 articles and 155/332 described cases (129 women, 26 men; age, 0-80 years) of presacral TGC in this study. Although most patients presented with complaints such as rectal bleeding, rectal fullness, perianal pain, constipation, and pain reflected to the back, some asymptomatic cases were identified incidentally and others were detected during the investigation of atypical complaints such as pilonidal abscess, sinus, vaginal obstruction, and perianal abscess. Malignant transformation was found in 47/332 cases, including adenocarcinoma (n = 26); carcinoid tumor (n = 16); endometrioid, adenosquamous, and squamous carcinomas; sarcoma; and paraganglioma.

CONCLUSIONS

The high rate of malignant disease development from TGCs, which comprise a significant proportion of presacral masses; the development of significant postoperative recurrence, causing atypical conditions such as perianal fistula; and the high rates of infection due to partial resections make it essential to perform complete tumor resection with adequate margins.

Liver transplantation with piggyback anastomosis using a linear stapler: a case report

The so-called piggyback technique of liver transplantation (PB-LT) preserves the recipient's caval vein, shortening the warm ischemic time. It can be reduced even further by using a linear stapler for the cavocaval anastomosis. Herein, we have presented a case of a patient undergoing a side-to-side, whole-organ PB-LT for cryptogenic cirrhosis. Upper and lower orifices of the donor caval vein were closed at the back table using a running 5-0 polypropylene suture. Three stay sutures were then placed on caudal parts of both the recipient and donor caval with a 5-mm venotomies. The endoscopic linear stapler was placed upward through the orifices and fired. A second stapler was placed more cranially and fired resulting in a 8-9 cm long cavocavostomy. Some loose clips were flushed away from the caval lumen. The caval anastomosis was performed within 4 minutes; the time needed to close the caval vein stapler insertion orifices (4-0 polypropylene running suture) before reperfusion was 1 minute. All other anastomoses were performed as typically sutured. The presented technique enables one to reduce the warm ischemic time, which can be of particular importance with marginal grafts.

Liver transplant with a marginal donor graft containing a hydatid cyst--a case report

Liver transplantation has become the standard treatment for acute failure and end-stage liver disease, but there are fewer donor organs available than patients on the waiting list. The donor pool may be increased by using marginal donor candidates. Some infectious and metabolic diseases have been transmitted to the recipient via marginal donor grafts. Hydatid cyst disease is rarely transmitted to a recipient from the donor graft. A literature search showed only 2 previous cases of liver transplantation using a donor graft that contains a hydatid cyst. We treated a 19-year-old woman who experienced acute on chronic end-stage liver failure secondary to cryptogenic cirrhosis. The liver graft from a 97-year-old marginal cadaveric donor contained a calcified hydatid cyst. No complication was associated with the hydatid cyst at 3 years after transplantation. The present case shows that donor livers with an inactive, calcified hydatid cyst may be used for emergency liver transplantation after considering the location, size, and relation of the cyst to vascular and biliary structures. The cyst may be resected on the back table with a successful treatment outcome.

Unusual cause of adult intussusception: diffuse large B-cell non-Hodgkin's lymphoma: a case report and review

BACKGROUND

Intussusception is defined as the telescoping of a segment of the gastrointestinal tract into an adjacent one. A demonstrable etiology is found in 70% to 90% of cases in adult patients, and about 40% of them are caused by a primary or secondary malignant tumor. The aims of this study were to give an overview of the literature on intussusception due to gastrointestinal lymphoma.

MATERIALS AND METHODS

We present a case of ileocecal intussusception secondary to non-Hodgkin's lymphoma (NHL), as well as a literature review of studies published in the English language on intussusception secondary to lymphoma, accessed through PubMed and Google Scholar databases.

RESULTS

Thirty-six published cases of intussusception caused by lymphoma were evaluated, and a case of ileocecal lymphoma in a 62 year-old woman is herein presented. In the reviewed literature, 33 reports meeting the aforementioned criteria were included in this review. The patients were aged from 16 to 86 years (mean, 48.2 +/- 19.0 y). Twenty-nine were male and seven were female. According to the localization of lymphoma, 24 patients had ileo-colic intussusception, 10 had enteric, and 2 had colic intussusception. In terms of the diagnosis, 34 patients were diagnosed with various types of NHL, and two patients were diagnosed with HL.

CONCLUSIONS

Despite the rarity of intussusception cases secondary to malignant causes, particularly lymphoma, it is rather difficult to diagnose preoperatively by surgeons. Because there exists a risk of malignancy in a substantial portion of adult intussusception cases, resection should be performed in a manner consistent with the oncological principles.

Chronic graft-versus-host disease after liver transplantation: a case report

Graft-versus-host disease (GVHD) after orthotopic liver transplantation (OLT) is a rare but significant complication, occurring in 1%-2% of cases with a mortality rate of 85%- 90%. It occurs when donor passenger lymphocytes mount an alloreactive response against the host's histocompatibility antigens. It presents as fever, rash, and diarrhea with or without pancytopenia. Between March 2002 and September 2011, among 656 OLT patients 1 (0.15%) had acute GVHD. A biopsy at the 7th posttransplantation month revealed chronic GVHD. Consequently, in the cases that had fever, rash, and/or desquamation of the any part of body after liver transplantation, GVHD must be considered and skin biopsies must be planned for the diagnosis.

Is routine sternotomy necessary for organ recovery from deceased donors? A comparative retrospective study

BACKGROUND

Traditionally, sternotomy and laparotomy are performed to recover thoracoabdominal organs from deceased donors; however, recovering abdominal organs without sternotomy is possible. We evaluated and compared organ recovery from deceased donors, with and without sternotomy.

METHODS

Between February 2006 and November 2011, organ recovery was performed in 68 deceased donors by our transplantation team. The recovery procedure was carried out using standard techniques in 31 donors (with sternotomy; Group A) and with modified techniques in 37 donors (without sternotomy; Group B). Average age, gender, body mass index (BMI), and time to cold ischemia were compared retrospectively in both groups. The demographic and clinical parameters were compared using a Student t test and chi-square test. The level of statistical significance was set at P < .05.

RESULTS

Organ recovery was performed on 31 of 67 (45.6%) deceased donors with sternotomy (Group A) and 37 of 67 (54.4%) without sternotomy (Group B). Thirty-six donors were male and 32 were female. The average donor age was 40.4 ± 3.4 years in Group A and 52.4 ± 4.6 years in Group B (P < .02). The average BMI of donors was 26.2 ± 0.8 kg/m(2) in Group A and 23.9 ± 0.8 kg/m(2) in Group B. The average time to cold ischemia was 127 ± 6.2 minutes in Group A and 47.5 ± 1.8 minutes in Group B (P < .0001).

CONCLUSION

The transition time to cold ischemia can be shortened by harvesting organs without sternotomy in unstable donors, or under conditions in which intrathoracic organs are not recovered.

QT Dispersion is Not Increased in Familial Mediterranean Fever

Familial Mediterranean fever (FMF) is an autoimmune disease inherited as an autosomal recessive trait and is characterized by recurrent attacks of fever and sterile polyserositis. This study examined electrocardiographic ventricular repolarization parameters (QT interval and QT dispersion) in 38 FMF patients and 35 healthy controls. The QT interval was measured manually from the onset of QRS to the end of the T wave (return to the TP baseline). QT dispersion was defined as the difference between the maximum and minimum QT values, and corrected QT was calculated according to the Bazett formula. There were no significant differences between FMF patients and healthy control subjects in any parameter of ventricular repolarization; hence QT dispersion was not affected by FMF. Electrocardiographic assessment of QT interval and QT dispersion are, therefore, of little value for the evaluation of cardiac impairment and risk of arrhythmia in FMF patients.

Appendicular tuberculosis: review of 155 published cases and a report of two cases

PURPOSE

This paper provides an overview of the literature on appendicular tuberculosis (ATB) between 1909 and 2010.

METHODS

We present two cases of primary ATB and a literature review of studies on ATB published in English and accessed via the Pubmed and Google Scholar databases.

RESULTS

One hundred fifty-five published cases of ATB were reviewed, and two patients with primary ATB, treated and followed in our clinic, were reported. The age range of the patients (62 females, 60 males and 33 with unnoted gender) was between 2 and 60 years, with a mean age of 27.1 ± 10.6 years. Of the patients who had applied to hospital, 59 had acute right lower quadrant pain, 46 had recurrent right lower quadrant pain, 19 had generalized pain, and 10 had chronic abdominal symptoms suggestive of subacute intestinal obstruction, while 47 patients were operated on with a diagnosis of acute appendicitis, 24 with recurrent appendicitis, 19 with TB peritonitis, 14 with mass in the right lower quadrant, 13 with subacute intestinal obstruction, and 7 with ATB. While appendectomy was not performed on 4 patients, one or more of the following procedures were done in the other 151 cases: appendectomy, hemicolectomy, ileocecal resection, or cecectomy. Different anti-tubercular treatment regimens with durations varying from 3 weeks to 18 months were applied to 60 patients. During the follow-up period of 3 weeks to 15 years, mortality occurred in 14 patients, sinus in five, and fistula in one patient. Secondary ATB was detected in 86 patients, primary ATB in 50, and no differential diagnosis could be made in 19 cases.

CONCLUSIONS

Tuberculosis is a systemic disease with localized manifestations; therefore, anti-TB therapy must be initiated in any patient whose pathologic specimen reveals tuberculosis.

A familial tendency for developing inguinal hernias: study of a single family

PURPOSE

Inguinal hernias are the most common abdominal wall rupture, and the predisposing factors to hernia formation include a familial tendency, connective tissue and lung diseases, smoking and prostatism. The aim of this study is to discuss the familial tendency for hernia in 5 members of a family of 11 people. To our knowledge, no other large family with inguinal hernias has been reported in the English literature.

METHODS

This study presents the surgical procedures and follow-up results of right inguinal hernias seen in 5 of 11 members from one family. Age, sex, body mass index (BMI), biochemical parameters, type of hernia and surgical procedure, and follow-up results were evaluated retrospectively.

RESULTS

This study included five patients (three males, two females) presenting with right direct inguinal hernias. The initial symptoms began at an average age of 18.2 years (range 15-22), and the mean BMI of the patients was 20.6 kg/m(2) (range 19.3-22.1). Three underwent hernia repairs with polypropylene surgical mesh and two with polyglactin-polypropylene composite mesh (Vypro II). The patients' blood vitamin C levels were lower than those of the other family members, while their 24-h urinary hydroxyproline levels were higher. The patients were followed for an average of 16.4 months (range 3-33 months). No complications developed during follow-up.

CONCLUSION

The occurrence of the same type of hernia in more than one family member and the altered biochemical results indicate that the hernias may have resulted from a familial connective tissue disease. In patients with hernias, if a familial tendency is suspected, a detailed examination for connective tissue diseases may help to confirm the diagnosis.

Scar endometriosis in the abdominal wall: a predictable condition for experienced surgeons

PURPOSE

Endometriosis in surgical scars develops in 0.1% of those women who undergo Caesarean section or other obstetric surgery. Herein we analyse and discuss the clinico-pathological characteristics of 15 patients with scar endometriosis in the abdominal wall.

METHODS

Fifteen cases of scar endometriosis in the abdominal wall that were treated surgically in our department between 2003 and 2009 were examined retrospectively. Age, parity, complaint, medical or surgical history, pre/postoperative hormonotherapy, size of the mass, surgical procedure, follow-up and disease recurrence were analysed.

RESULTS

This retrospective study included 15 patients presenting with 17 postoperative abdominal wall masses. The mean age of the patients was 32.1 +/- 6.0 years (range, 23-48). Eleven of the patients had a painful mass that became bigger before menstruation, two had palpable masses only, and two were hospitalised because of a mass with persistent pain. The locations of the masses were as follows: eight were close to the right side and three were close to the left side; two were in the middle of the Pfanenstiel incision and two were in trocar tracts. The patients' surgical histories included Caesarean section in thirteen, bilateral laparoscopic ovarian cyst excision in one, and laparoscopic appendectomy in one.

CONCLUSIONS

If a patient presents with incision pain and a palpable mass after gynaecologic surgery, an incisional endometrioma should be considered. Surgical excision and hormone therapy are effective treatment approaches in these patients.

Preemptive living donor renal transplantation: a single-center experience

Renal transplantation is considered preemptive if it occurs before initiation of dialysis. In our experience and in the literature, preemptive transplantation has been shown not only to reduce the costs of renal replacement therapy but also to avoid the long-term adverse effects of dialysis. Preemptive renal transplantation therefore is associated with better survival of both the allograft and the recipient. Our aim was to evaluate the outcomes of preemptive renal transplantation experience at our center. Since 1985, 1385 renal transplantations have been performed at our center. We retrospectively analyzed the 16/1385 recipients (11 male, 5 female) of overall mean age of 28.5 +/- 15 years who underwent preemptive procedures. The causes of end-stage renal failure were focal segmental glomerulosclerosis (n = 5), vesicular ureteral reflux (n = 4), Berger disease (n = 2), polycystic renal disease (n = 2), and others (n = 3). Ten patients were adults, the remaining six, children. The mean creatinine clearance and plasma creatinine levels of the recipients before renal transplantation were 13.5 +/- 8.5 mL/min and 6.7 +/- 2.4 mg/dL, respectively. All renal transplantations were performed from living related donors. The mean preoperative serum creatinine levels, mean glomerular filtration rate, and creatinine clearance rates of the donors were 0.8 +/- 0.1 mg/dL, 61.6 +/- 6.5 mL/min, and 112.5 12 mL/min, respectively. Two episodes of acute cellular rejection and one of humoral rejection occurred during a mean follow-up of 48.7 +/- 14 months (range = 25-76 months). The two patients who experienced graft losses due to humoral rejection or chronic rejection were retransplanted 2 and 48 months thereafter, respectively. At this time all patients are alive with good renal function. In conclusion, our single-center results are promising for preemptive renal transplantation as the optimal, least-expensive mode of treatment for end-stage renal disease.

Castleman's disease as cervical mass: a report of three cases and review of the literature

Castleman disease is a rare disorder characterized by benign lymph node hyperplasia involving lymphatic tissue in the neck, mediastinum, abdomen and other areas. Disease was described for the first time in 1956 by Castleman. The etiopathogenesis of the disease is unknown. The disorder can be classified into three histopathological types: hyalin-vascular, plasma-cell and mixed. We report three cases of the Castleman's disease (hyaline-vascular type) in three female patients with unilateral swelling of the neck. None of the patients developed any local or distant recurrence in postoperative follow-up.

Measurement of solid-liquid interfacial energy in the pyrene succinonitrile monotectic system

The equilibrated grain boundary groove shapes for solid pyrene (PY) in equilibrium with the PY succinonitrile (SCN) monotectic liquid were directly observed. From the observed grain boundary groove shapes, the Gibbs-Thomson coefficient and solid-liquid interfacial energy for solid PY in equilibrium with the PY SCN monotectic liquid have been determined to be (8.72 ± 0.87) × 10(-8) K m and (21.9 ± 3.28) × 10(-3) J m(-2) with the present numerical method and Gibbs-Thomson equation, respectively. The grain boundary energy of the solid PY phase has been determined to be (42.84 ± 7.28) × 10(-3) J m(-2) from the observed grain boundary groove shapes. Thermal conductivities of solid and liquid phases for PY-2.5 mol% SCN alloy and pure PY have also been measured.

Modification of hydraulic conductivity in granular soils using waste materials

This paper evaluates the use of waste products such as silica fume and fly ash in modification of the granular soils in order to remove some environmental problems and create new useful findings in the field of engineering. It is known that silica fume and fly ash, as well as clay material, are used in geotechnical engineering because of their pozzolanic reactivity and fineness to improve the soil properties needed with respect to engineering purposes. The main objective of this research project was to investigate the use of these materials in geotechnical engineering and to improve the hydraulic properties of soils by means of grouting. For this reason, firstly, suitable grouts in suspension forms were prepared by using silica fume, fly ash, clay and cement in different percentages. The properties of these cement-based grouts were then determined to obtain the desired optimum values for grouting. After that, these grouts were penetrated into the soil samples under pressure. The experimental work indicates that these waste materials and clay improved the physical properties and the fluidity of the cement-based grouts and they also decreased the hydraulic conductivity of the grouted soil samples by sealing the voids of the soil. The results of this study have important findings concerning the use of these materials in soil treatment and the improvement of hydraulic conductivity of the soils.

Primary squamous cell carcinoma of the stomach: a case report

Primary squamous cell carcinoma (SCC) of the stomach is a very rare tumour. We report a case of SCC of the stomach in a 56-year old woman who had metastases to the liver and abdominal lymph nodes.

Primary chest Hodgkin's disease diagnosed by pleural biopsy: case report

Hodgkin's disease involving the lung and pleura is rare. A case of a 40-year-old woman with one year history of pain in the left arms spreading into chest is presented. Computed tomography showed a mass of 5 x 7 cm in the left hemithorax mediastinum and pleura, pleural effusion and mediastinal lymphadenopathy. Diagnostic methods including percutaneous needle aspiration biopsy of pleura, brochoscopic biopsies, bronchoalveolar lavage, cytological examination of the pleural fluid did not disclose any pathological diagnosis. Lastly, we performed pleural biopsy by video-assisted thoracoscopic surgery and we showed that the lesion was HD of nodular sclerosing type.

Acute phase response during radiotherapy

PURPOSE

The acute phase response is characterized by changes in the plasma concentrations of a number of liver-synthesized proteins, one of which is C-reactive protein (CRP). The existence of these changes in the plasma profile underlies the change in erythrocyte sedimentation rate (ESR). Acute phase response itself is an illness and may result from immunologic reactions and inflammatory processes. This study is designed to determine whether the CRP level and ESR increase during radiotherapy and whether their rise correlates with acute and late radiation morbidity.

METHODS AND MATERIALS

Between April 1997 and October 1998, 51 patients with the diagnosis of endometrium and cervical cancer were treated with surgery and postoperative radiotherapy. Median age at the time of radiotherapy was 52 (range, 26-73) years. Thirty patients received pelvic radiotherapy, and 21 patients were treated by pelvic-paraaortic irradiation. A total dose of 50.4 Gy to the pelvis and 45 Gy to the paraaortic field were delivered in conventional fraction. Erythrocyte sedimentation rates and CRP levels were studied before, during, and at the end of radiotherapy.

RESULTS

The mean ESR measurements before and after radiotherapy were 40 (8-100) and 52 (10-120), and mean CRP levels were 1.4 (0.12-9.8) and 2.7 (0.12-32.2), respectively. The statistical analysis yielded significant rise in ESR and CRP levels at the end of radiotherapy (p < 0.001). The increase was more prominent in patients who were irradiated through pelvic-paraaortic field than in patients with pelvic radiation (p = 0.005 and 0.028 respectively).

CONCLUSION

Acute phase response was present during radiotherapy. Radiotherapy should be considered as a cause of increase in CRP level and ESR especially in clinical conditions where acute phase response is important.

Expression of the melanocortin 5 receptor on rat lymphocytes

The expression of melanocortin-5 receptor (MC5-R) mRNA and protein was characterized from isolated rat lymphocytes. The presence of MC5-R mRNA in spleen and thymus tissues was demonstrated by RT-PCR. The RT-PCR product was sequenced to confirm the identification of MC5-R. Tissues from lachrymal glands, adipose, adrenals, thymus, pancreas, and isolated splenic lymphocytes were detergent solubilized. The crude proteins were resolved by SDS-PAGE, transblotted to a nitrocellulose membrane, and probed for MC5-R using anti-receptor rabbit antisera. Two different types of polyclonal rabbit antisera were raised against synthetic peptides representing epitopes found at the amino (alphaN-MC5-R) and the carboxyl termini (alphaC-MC5-R) on the MC5-R. A prominent band at 77,000 (p77) was detected in all tissues except the pancreas. Preimmune sera did not detect p77 by Western analysis and the addition of peptide antigen neutralized the detection of p77 by the specific antisera. The receptor protein was purified from spleen and thymic lymphocytes using protein A agarose that precipitated material complexed to alphaN-MC5-R. The purified MC5-R was detected by Western analysis using alphaC-MC5-R. Both anti-receptor antisera, alphaN-MC5-R and alphaC-MC5-R, detected the p77. The p77 was treated with protein endoglycosidase F to produce a smaller protein band between 34-38,000 (p35); the inferred size is 37,000 based on the cDNA sequence. The data suggest that Asn-linked carbohydrate groups account for much of the p77 mass of the MC5-R. The data also demonstrate the expression of MC5-R protein on rat lymphocytes, thus, supporting the hypothesis that MC5-R is the ACTH receptor on lymphocytes.

Choroid metastasis of undifferentiated nasopharyngeal carcinoma

Choroid metastasis of primary nasopharyngeal carcinoma is an infrequent event. Here, we report a case of nasopharyngeal carcinoma with metastases to the choroid successfully treated by external beam radiotherapy.