The role of laparoscopic sleeve gastrectomy on inflammatory parameters in morbidly obese patients.

BACKGROUND: Obesity is an excessive increase in body fat mass and triggers chronic inflammation which causes increased fat accumulation in the visceral fat tissue. The aim of this study was to analyze serum zinc (Zn), Zn-alpha 2 glycoprotein (ZAG), peroxisome proliferator-activated receptor-γ (PPAR-γ) and nuclear factor kappa-light-chain-enhancer of activated B cell (NF-κB) levels in morbidly obese patients before and after laparoscopic sleeve gastrectomy (LSG) and determine the association between alteration in body mass index (BMI), the % Excess Weight Loss (% EWL) and the biochemical parameters. METHODS: Thirty healthy individuals as a control group and 30 morbidly obese patients who had undergone LSG were enrolled in this study. Routine anthropometric and laboratory biochemical parameters in venous blood samples of groups at baseline and 1 and 12 months after LSG were recorded. RESULTS: Significant weight loss was achieved at 1 and 12 months after LSG. At baseline serum ZAG and PPAR-γ levels were lower, while NF-кB levels were higher in morbidly obese patients compared with the control group. Serum ZAG and PPAR-γ levels increased while NF-кB levels decreased 1 month and 12 months after LSG. Decreased %EWL was negatively correlated with changes in NF-кB, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), fasting plasma glucose and insulin at 12 months after LSG in morbidly obese patients. However, %EWL was positively correlated with changes in ZAG. CONCLUSIONS: Obesity was associated with down-regulated serum ZAG and PPAR-γ levels while up-regulated serum NF-кB. Our findings suggest that LSG ameliorates upregulating PPAR-γ expression, thereby inhibiting NF-κB-mediated inflammation by weight loss.

Gastrointestinal stromal tumors of the stomach: A 10-year experience of a single-center.

BACKGROUND: Gastrointestinal tract stromal tumors (GIST) are the most common mesenchymal tumors in the gastrointestinal tract (GIS). GISTs may cause significant morbidity and mortality rates. AIM: In this study, it was aimed to evaluate 10 years of gastric GIST cases followed in our hospital, and to analyze the prognostic factors. SUBJECTS AND METHODS: In this single-center retrospective study, a total of 64 patients who were operated between May 2010 and May 2020 due to gastric GIST tumor were reviewed. Clinical and pathological features, risk classifications, overall survival (OS) and disease-free survival (DFS) were evaluated. RESULTS: According to the risk classification, 18.8% of the patients were in the high-risk group. The overall 5-year OS and DFS rates were 85.7%. The mean OS of the patients was 47.9 SD36.2 months, and the duration of DFS was 45.5 months. Patients with a 5-year OS rate above 5 cm in diameter (P = 0.024), with a mitotic index above 5/50 high power field (HPF) (P = 0.038), and those with a high-risk group (P = 0.011) were significantly lower than the other group. In the correlation analysis, it was found that tumor diameter correlated significantly with OS (P = 0.034; r = -0.317). Tumor diameter and mitotic index were found to be inversely correlated with DFS duration (P = 0.004; r = -0.425 and P = 0.035; r = -0.316, respectively). CONCLUSION: Our findings showed that in gastric GIST cases, as the primary tumor diameter and mitotic index increase, correlate with survival rates and the mean overall and disease-free survival times decrease.

How the Aperture of Femoral Tunnel Affected in ACL Reconstruction Performed with AM Portal Technique?

PURPOSE OF THE STUDY The purpose of this study was to evaluate the position of tibial tunnel (TT) and femoral tunnels (FT) performed by using the anteromedial (AM) portal technique and its effect on the aperture of FT. MATERIAL AND METHODS A total 44 patients operated for anterior cruciate ligament (ACL) rupture by AM portal technique between January 2013 and July 2015, were included in this study. They were subjected to a magnetic resonance imaging of the knee to assess the FT, dimensions of the FT aperture and TT. The location of the ACL graft within the joint was compared with the intact ACL of healthy individuals. The patients were also evaluated using Lysholm and IKDC subjective scores for functional outcome. RESULTS The mean FT angle on both the coronal plane (42.88°±5.83°) and the sagittal plane (68.47°±9.57°) was significantly different from the intra-articular part of the hamstring autograft angles (74.93°±7.27° and 58.74°±4.88°, respectively) (p<0.0001). The mean distance of the FT aperture was 13.18 (±2.49) mm on vertical axis, 10.97 (±1.50) mm on the sagittal axis (p<0.0001). The difference between TT axis and the axis of the intra-articular part of autograft on both coronal (72.78°±4.67° and 74.93°±7.27°, respectively) and sagittal planes (60.12°±5.53° and 58.74°±4.88°, respectively) were not significant (p>0.05). DISCUSSION Ilingrowth et al. claimed that the FT were scattered in the very large distance and some of them were placed outside of anatomical range in the series included the cases performed with transtibial and transtibial independent techniques. In this series, in which we used a femoral guide to drill the FT at lateral femoral condyle at 2 or 10 o'clock position depended upon the site of operation, we obtained a consistent FT which is comparable with the intra-articular part of native ACL. Amano et al. found that the FT aperture enlargement was significant in the series when hamstring tendons were used as autograft, over a 6-month period. We also found a significant difference between the narrowest part of the FT (7.01 ± 1.05 mm) and its aperture (10.97 ± 1.50 mm in sagittal, 13.18 ± 2.49 mm in vertical direction). The enlargement was mainly in the vertical direction, due to the fact that the loads resulting from daily life are mostly on the horizontal plane. CONCLUSIONS The direction of intra-articular part of the ACL graft in the cases operated with the AM portal technique is significantly different from the FT direction in both the coronal and sagittal planes. The enlargement of the FT aperture is larger in the vertical axis compared to the sagittal axis. Although the long-term clinical consequences of asymmetrical enlargement of the FT aperture are not known yet, to avoid this potential risk, a technique to approximate the direction of FT to the intra-articular part of the ACL without changing the FT entry site, can be used. Key words: knee, anterior cruciate ligament reconstruction, femoral tunnel, tibial tunnel, anteromedial portal.

The role of genistein in experimental hepatic ischemia‒reperfusion model in rats.

Genistein is a natural compound from the class of isoflavonoids found in high concentrations in legumes and soybeans. In this experimental study; we suggest that genistein might cause favorable outcomes in the hepatic surgery because of its protective effects on hepatic ischemia‒reperfusion injury (Tab. 2, Fig. 6, Ref. 28). Keywords: genistein, isoflavonoids,legumes, soybeans, hepatic surgery, ischemia‒reperfusion injury.

Surgical Management of a Bilateral Bifid Condyle: Diagnosis, Three-dimensional Reconstruction, and Treatment - A Report of a Case and Review of the Literature.

Bifid condyle is a rare entity with a difficult diagnosis and usually identified as an incidental finding on routine radiographic examination. The etiology is not well known, possible causes may be developmental, traumatic, vascular, abnormal muscle pulling, nutritional, endocrinal, teratogenic, and infections. The orientation of the condylar heads can behelpful for the etiological diagnosis.This case report describes a 56-year-old woman who suffered from a unilateral, progressively increasing, radiating pain which intensified with the movement of the mandible and includes information about the diagnosis, management, radiographic and three-dimensional model features and review of the literature.

The value of plain X-rays in predicting TFCC injury after distal radial fractures.

In this prospective study, the plain X-rays and MRI scans of 60 patients with intraarticular distal radius fractures were examined in random order. MRI evaluation revealed that 27 of the 60 patients (45%) had triangular fibrocartilage lesions. No correlation was found between triangular fibrocartilage injury and the Melone classification system, the presence of an ulnar styloid fracture, comminution of the articular surface of the distal radius, >20 degrees dorsal angulation of the distal radius or subluxation/dislocation of the distal radioulnar joint on the plain X-rays. When Frykman Type VI and VIII fractures were compared with all the other Frykman subtypes, a significant difference in the incidence of triangular fibrocartilage complex tears was observed. We conclude that triangular fibrocartilage injury should be considered with all distal radial fractures, especially the Frykman Types VI and VIII.

Alveolar hydatid disease of the liver: brief review and spectrum of adjacent organ invasion.

The purpose of this study is to show the spectrum of adjacent organ invasion and to make a brief review of hepatic alveolar hydatid disease (AHD), using CT and MR imaging. We retrospectively reviewed CT and MR images of three patients with various adjacent organ invasions surgically and histologically proven to be AHD. Local invasion to right kidney and adrenal, right hemidiaphragm and lung were detected in one patient, right adrenal in another patient and gall bladder, duodenum, gastric wall and pancreas invasion in the other. AHD may rarely extend to the gall bladder, stomach, duodenum, pancreas, right adrenal and kidney, diaphragm, pleura and lung. The extension of the disease outside the liver is usually encountered in patients with large, peripherally located masses in the advanced stage of the disease.

Surgical treatment of complicated pilonidal disease: limited separate elliptical excision with primary closure.

OBJECTIVE: We aimed at treating complicated pilonidal sinus (PS) patients by a simple and effective surgical procedure. METHOD: Between 2000 and 2004, 24 selected complicated PS patients were treated with 'limited separate elliptical excision and primary closure'. Patients with extensive or bilateral gluteal involvement, having more lateral, caudal or cephalic sinuses, multiple recurrences and unhealed chronic wounds after pilonidal surgery were included. Asymmetric excision and primary closure was performed to main diseased tissue in the midline. Additionally, small separate elliptical excisions with primary closure were performed in other involved tissues. The fistula tract or granulation tissue were excised subcutaneously if present. All patients were operated under local anaesthesia. The fascial attachments between the skin and coccyx were released at the deep point in the midline and at one side of wound. Suction drains and prophylactic antibiotics were used; subcutaneous tissues were closed with running polyglactin sutures and skin with polypropylene subcutaneously. RESULTS: The mean age of patients was 28.4 years (range 18-38). The mean follow-up time was 2.8 years. One recurrence, one seroma, one wound infection and one wound breakdown were recorded. Healing was always by first intention except in patients with wound infection and breakdown. CONCLUSION: Most of the complicated PS patients can be operated with acceptable rates of recurrences and complications by using 'limited separate elliptical excisions with primary closure'.

Mucin macromolecules in normal, adenomatous, and carcinomatous colon: evidence for the neotransformation.

Mucins are high molecular-weight glycoproteins having oligosaccharides attached to serine or threonine residues of the mucin core protein backbone by O-glycosidic linkages. They are major components of mucus, covering the luminal surfaces of epithelial respiratory, gastrointestinal and reproductive tracts, and responsible for its viscoelastic properties. The core proteins of mucins are encoded by different mucin genes. Aberrations in the cell surface carbohydrates including mucins have been regarded as a universal characteristic of the malignant transformation of cells. These alterations are considered to be relevant to the abnormal behaviour of cancer cells, such as altered cell adhesion or metastasis, and to the avoidance of immunological defence.

Reliability of procalcitonin as a severity marker in critically ill patients with inflammatory response.

Procalcitonin (PCT) is increasingly recognised as an important diagnostic parameter in clinical evaluation of the critically ill. This prospective study was designed to investigate PCT as a diagnostic marker of infection in critically ill patients with sepsis. Eighty-five adult ICU patients were studied. Four groups were defined on the basis of clinical, laboratory and bacteriologic findings as systemic inflammatory response syndrome (SIRS) (n = 10), sepsis (n = 16), severe sepsis (n = 18) and septic shock (n = 41). Data were collected including C-reactive protein (CRP), PCT levels and Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores on each ICU day. PCT levels were significantly higher in patients with severe sepsis and septic shock (19.25 +/- 43.08 and 37.15 +/- 61.39 ng/ml) than patients with SIRS (0.73 +/- 1.37 ng/ml) (P < 0.05 for each comparison). As compared with SIRS patients, plasma PCT levels were significantly higher in infected patients (21.9 +/- 47.8 ng/ml), regardless of the degree of sepsis (P < 0.001). PCT showed a higher sensitivity (73% versus 35%) and specificity (83% versus 42%) compared to CRP in identifying infection as a cause of the inflammatory response. Best cut-off levels were 1.31 ng/ml for PCT and 13.9 mg/dl for CRP. We suggest that PCT is a more reliable marker than CRP in defining infection as a cause of systemic inflammatory response.

[The effect of pentaglobin therapy on prognosis in patients with severe sepsis]. / Agir sepsis hastalarinda Pentaglobin tedavisinin prognoz üzerine etkisi.

This study was designed to assess the effects of polyclonal immunoglobulin administration on septic shock incidence and prognosis in patients with severe sepsis. Patients with severe sepsis were randomly allocated into two groups. One group (n = 21) received 5 ml/kg/day IgM enriched immunoglobulin preparation (Pentaglobin) for 3 days. Other group did not receive immunoglobulins (n = 18). Simplified Organ Failure Assessment (SOFA) scores, leucocyte count, duration of mechanical ventilation, ICU stay, duration of severe sepsis did not show significant differences between the groups, as regards to septic shock incidence and mortality. However, a significant decrease in procalcitonin levels were detected only in patients who received pentaglobin (p = 0.001). Mortality rate was 5/21 (23.8%) in pentaglobin group and 5/18 (27.7%) in the control group. Although pentaglobin therapy could not achieve a statistically significant improvement in septic shock occurrence and mortality, the constant reduction in procalcitonin levels indicated the beneficial effects of immunotherapy on the severity of inflammatory response to infection in severe sepsis.

Clinical applicability of the substitution of mixed venous oxygen saturation with central venous oxygen saturation.

OBJECTIVE: To examine the clinical applicability of substituting central venous oxygen saturation (ScvO2) for mixed venous oxygen saturation (SmvO2) in monitoring global tissue oxygenation. DESIGN: Prospective clinical investigation. SETTING: University hospital. PARTICIPANTS: Seventy-three adult patients. INTERVENTIONS: Venous oxygen saturation was recorded, and oxygen saturation difference between SmvO2 and ScvO2 (DeltaSmvcv) was calculated in 2 groups of patients (group I, sepsis patients [n = 41], and group II, general anesthesia for cardiovascular surgery patients [n = 32]) during initial placement of pulmonary artery catheters. MEASUREMENTS AND MAIN RESULTS: Patients were classified as follows: class A, patients having a DeltaSmvcv >-5%; class B, patients having a DeltaSmvcv between -5% and +5%; and class C, patients having a DeltaSmvcv >+5 %. Statistically significant differences were observed in cardiac index, oxygen delivery index, and oxygen extraction ratio between class A and B in both groups. Class C of group II showed the worst correlation between SmvO2 and ScvO2 and had significantly lower arterial carbon dioxide tension values than class A and B. CONCLUSION: Pulmonary artery blood sampling should not be replaced with central venous blood. Hypocapnia and increased oxygen extraction ratio seem to be the major factors that worsen the relationship between ScvO2 and SmvO2.

The value of pre-emptive analgesia in the treatment of postoperative pain after laparoscopic cholecystectomy.

BACKGROUND AND AIM: Postoperative pain is an important surgical problem. Recent studies in pain pathophysiology have led to the hypothesis that with pre-operative administration of analgesics (pre-emptive analgesia) it may be possible to prevent or reduce postoperative pain. This study was planned to investigate the efficacy of pre-emptive analgesia on postoperative pain after laparoscopic cholecystectomy. METHODS: 45 patients undergoing laparoscopic cholecystectomy were randomized into three groups. Bupivacaine was injected into the area of skin incision before trocar entry and after trocar removal in group 1 and 2, respectively; however, this procedure was not applied to the control group. The pain score of the patients was evaluated by the visual analogue scale (VAS) at 1, 4, 12( )and 24 h after surgery. The daily analgesic requirement was evaluated in terms of diclophenac sodium (Diclomec, Abdi Ibrahim, 75 mg) intake/day. Analgesics were given to the patients whose VAS was 5 or higher. RESULTS: While there was no significant difference in VAS scores between group 1 and 2, the mean pain scores of these two groups were found to be significantly lower than of the control group although the analgesic requirement of the patients in each group was not statistically significant. CONCLUSION: Pre-emptive analgesia is as effective as postsurgical local anaesthesia in reducing postoperative pain.

Modified technique for correction of gynaecomastia.

OBJECTIVE: To test a modification of the circumareolar incision for correction of a gynaecomastia from the points of view of complications and appearance of the scar. DESIGN: Clinical study. SETTING: Military and university hospitals, Turkey. SUBJECTS: 32 patients with gynaecomastia operated on between 1992 and 2000. INTERVENTIONS: Simon I patients were treated with an inferior semicircular periareolar incision (n = 12). Half of the Simon II patients had the same incision and the others were treated with a modified extended incision (n = 10 in each group). MAIN OUTCOME MEASURES: Haematoma, skin necrosis, nipple inversion, low-seated nipple, asymmetry, hypoaesthesia and hypertrophic scar. RESULTS: Simon II patients treated with the unmodified incision had more haematomas and seromas than Simon I patients and worse cosmesis (p = 0.009 and p = 0.02). However, the complication rates did not differ significantly compared with the Simon II patients who had the modified incision. CONCLUSION: A modified extended circumareolar incision results in fewer complication and better cosmesis in grade II gynaecomastia than the standard incision.

Systemic stress responses after laparoscopic or open hernia repair.

OBJECTIVE: To compare systemic stress responses after laparoscopic and open hernia repair to find out if the laparoscopic approach caused less stress than an open operation. DESIGN: Prospective randomised trial. SETTING: Teaching hospital, Sanliurfa, Turkey. SUBJECTS: 50 patients who required preperitoneal hernia repair were randomised to be treated by either the open or laparoscopic approach (n = 25 in each). INTERVENTIONS: Samples of venous blood were taken before operation and at 2, 24, and 48 hours afterwards for measurement of the concentrations of: glucose, cortisol, malonyldialdehyde (MDA), C-reactive protein (CRP), creatine phosphokinase (CPK), caeruloplasmin, transferrin, fibrinogen, and albumin, and counts of leucocytes, neutrophils, and lymphocytes. MAIN OUTCOME MEASURES: Changes in these indicators of a stress response. RESULTS: Concentrations of glucose, cortisol, CRP, MDA, and CPK, and counts of leucocytes and neutrophils increased significantly, and the concentration of albumin decreased significantly, in both groups postoperatively. Lymphocyte counts were lower postoperatively but not significantly so. Concentrations of CRP, MDA, and CPK, and leucocyte counts were significantly lower in the laparoscopic group. CONCLUSION: These findings suggest that there is less systemic stress response after laparoscopic than after open hernia repair.

Simple and effective surgical treatment of pilonidal sinus: asymmetric excision and primary closure using suction drain and subcuticular skin closure.

PURPOSE: This study was planned to evaluate prospectively the results of 112 pilonidal sinus cases treated surgically by using asymmetric excision and primary closure with suction drain and subcuticular skin closure. It is aimed at elimination of the causative factors of pilonidal sinus. METHOD: The patient's age, profession, weight and height, symptoms and signs, duration of symptoms, previous treatments, operation time and cost, hospital stay, return to normal activity, complications, pathologic and microbiologic examinations, and recurrences were noted. All pilonidal sinus cases except pilonidal abscess and extensive gluteal involvement were treated surgically. The procedure consists of an eccentric, elliptical excision of the affected tissue, mobilization of the flap to the sacrococcygeal fascia and the suturing of its edge to the lateral one. Penrose drains were placed in the first eight (7.14 percent) cases, but suction drains were placed in others. The cases were followed up for a mean of 2.4 years. RESULTS: Twenty-eight (25 percent) cases had undergone previous operative procedures. Of 112 patients 106 (94.6 percent) were male. Mean age was 22.1 years. Mean history of disease was 4.2 years. The overall complication rate was 7.14 percent. Two (1.8 percent) wound infections, two wound breakdowns, three (2.7 percent) collections, and one (0.9 percent) recurrence were recorded. The collections were reduced to zero after first eight cases by using a suction drain. Sixty-eight of the patients (60.7 percent) had body weight over 90 kg, and the mean body mass index was 24.8. The mean hospital stay was 2.6 days, and the mean time off work was 12.4 days. The average healing time was 13.2 days. There were no anesthetic or surgical deaths. CONCLUSION: The natal cleft is flattened and the incision scar and the incision line is transferred from the midline to the lateral side by performing the asymmetric excision and primary closure, and thus the essential cause of pilonidal sinus is eliminated. The procedure is simple, the complications and recurrences are very low, and it is seen to be an excellent procedure in the surgical treatment of uncomplicated pilonidal sinus disease.

Effects of antiadhesive agents on the healing of intestinal anastomosis.

PURPOSE: The effects of antiadhesive agents on the healing of intestinal anastomosis were investigated. METHODS: Eighty rats were divided into eight groups. Colotomy and anastomosis were performed to all rats. Saline solution (control), carboxymethylcellulose, aprotinin, verapamil, tenoxicam, cyclosporine, and dextran 70 were administered intraperitoneally. Vitamin E was administered intramuscularly. The rats were killed 15 days later. Anastomotic healing was assessed by bursting pressure and the hydroxyproline content of the anastomotic tissues. The results were evaluated by Mann-Whitney U test. RESULTS: The mean (+/- standard deviation) bursting pressures of carboxymethylcellulose, cyclosporine, and aprotinin groups (108 +/- 6.73, 122.5 +/-14.39, and 127 +/- 20.23, respectively) were significantly lower than those of the control group (234 +/- 6.19). The mean level of hydroxyproline in the anastomotic tissues was significantly lower in the carboxymethylcellulose and cyclosporine groups (8.92 +/- 0.6 and 8.32 +/- 0.63) than that in the control group (16.33 +/- 0.68). CONCLUSION: These findings indicate that carboxymethylcellulose and cyclosporine had adverse effects on intestinal anastomosis in rats.