META Score: An International Consensus Scoring System on Mesh-Tissue Adhesions.

BACKGROUND: Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery. METHODS: Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting. RESULTS: The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions. CONCLUSION: The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes.

Management of isolated duodenal rupture due to blunt abdominal trauma: case series and literature review.

INTRODUCTION: Duodenal injuries are uncommon and are associated with significant morbidity and mortality due to delayed diagnosis (in the case of blunt trauma) or associated major vascular injuries (in the case of penetrating trauma). Isolated blunt injuries may have a subtle clinical presentation, and are particularly difficult to diagnose when the perforation is located in the retroperitoneal part of the duodenum. MATERIALS AND METHODS: This paper presents in company with three cases of successfully treated isolated duodenal injuries due to blunt trauma, focusing on with their preoperative diagnosis, surgical management and final out comes. CONCLUSIONS: Early diagnosis and successful surgical planning require experience and clinical suspicion on the part of the surgeon, as well as meticulous laparotomy results.

Impact of fibrin sealant on Limberg flap technique: results of a randomized controlled trial.

BACKGROUND: Pilonidal disease is a common chronic disorder mainly seen in the sacrococcygeal region, especially in young males. Different surgical methods have been described for the treatment. Limberg flap has low morbidity and recurrence rates. Fibrin sealant, a two-component tissue adhesive composed of fibrinogen and thrombin, has been used in a number of surgical procedures to achieve hemostasis and to seal tissues. The purpose of this study was to investigate the impact of fibrin sealant on the Limberg flap procedure. METHODS: Between January 2003 and January 2004, 32 male patients with pilonidal disease were randomly assigned to receive the standard Limberg flap technique (n=16) alone or with fibrin sealant application (n=16) before drain insertion. RESULTS: The two groups were similar for age and body mass index. The total drainage volume was 64.4+/-28.0 ml in the control group and 16.2+/-13.6 ml in the fibrin sealant group (p<0.001). Moreover, hospitalization time was 3.9+/-0.6 days in the control group and 2.0+/-0 days in the fibrin sealant group (p<0.001). CONCLUSIONS: Use of fibrin sealant for Limberg flap technique shortens hospitalization time, reduces drainage volume and is therefore recommended.

Are clips useful in the surgical repair of colonic perforations?

PURPOSE: The objective of this study was to assess the effecacy of clip application in the surgical repair of iatrogenic colonic perforations. MATERIAL AND METHODS: Twenty adult male Wistar-Albino rats were divided into two equal groups of ten. In both of the groups an iatrogenic perforation was made in the anti-mesenteric border of the left colon. The defect was closed with interrupted 6/0 polypropylene sutures in group 1 and extraluminal application of vascular clips (VCS--vascular clip system) in group 2. All animals were killed on postoperative Day 4. Wound healing was evaluated with both in situ bursting pressure and hydroxyproline levels. RESULTS: There was no statistically significant difference between the two groups in respect of bursting pressure levels (p = 0.063) whereas hydroxyproline levels were higher in group 2 (p = 0.0021). CONCLUSIONS: Surgical repair of iatrogenic colonic perforations by extraluminal clips gives comparable results according to wound healing parameters. This approach may be a rational alternative to suture or endoscopic repair methods.

Is intraluminal clip application an appropriate treatment for iatrogenic gastric perforation?

BACKGROUND: The standard treatment of iatrogenic perforation has been an urgent operation. Recently, endoscopic clip application was recommended particularly for iatrogenic perforations. This study was designed to investigate the usage of surgical clips for gastric perforations. METHOD: Forty male rats were allocated to four groups. Following a midline laparotomy, a 5-mm gastrotomy was made at the fundic part of the stomach and through this ostomy a pre-pyloric perforation was created in all groups. In group I, the perforation site was closed with polypropylene sutures. In group II, the perforation site was closed extraluminally by vascular surgical clips. In group III, the perforation site was closed intraluminally by the same number of clips. In group IV, control group, the perforation site was left open. The animals were sacrificed on the 4th postoperative day. The healing of the perforation site was evaluated by the bursting pressure and the hydroxyproline content of the suture line. RESULTS: Measurements revealed no differences in bursting pressure and hydroxyproline levels between the intraluminal clip application group (group III) and the group in which the perforation site was left open (group IV) (p > 0.05). Higher bursting pressures and hydroxyproline levels were observed in groups I and II compared to control group (p < 0.05). CONCLUSIONS: These results suggest that gastric perforations are not strengthened by intraluminal clip application. Further detailed clinical studies are necessary in order to conclude that intraluminal clip application is an appropriate treatment for iatrogenic perforation.

Bowel cleansing for diagnostic colonoscopy: which method is preferable? Istanbul experience.

BACKGROUND: A prospective randomized trial to assess the cleansing ability and tolerance of bowel preparations for colonoscopy was conducted in a group of 953 patients. METHODS: The bowel cleansing methods were: sennoside calcium, polyethylene glycol (PEG) lavage, oral sodium phosphate (NaP) in one 90-ml dose, oral NaP in 2 doses (90 ml + 45 ml), oral NaP in 2 doses (45 ml + 90 ml), oral NaP in 2 doses (45 ml + 90 ml) plus cisapride, and oral NaP in 2 doses (45 ml + 90 ml) plus domperidone. RESULTS: The cisapride-containing procedure was abandoned partially through the study because of its adverse effects. The colon cleansing ability in groups with NaP plus cisapride and NaP plus domperidone was significantly better than the other groups ( p<0.05). Tolerance to sennoside calcium and PEG lavage in comparison to the other groups was significantly worse ( p<0.05). CONCLUSION: Two doses of NaP solution (45 ml + 90 ml) plus domperidone for colon cleansing is safe, effective, rapid, inexpensive and well tolerated.

Castleman's disease masquerading as sigmoid colon tumor and Hodgkin lymphoma.

Castleman's disease is a benign lymphoid neoplasm first reported as hyperplasia of mediastinal lymph nodes. Some authors referred to the lesions as isolated tumors, described as a variant of Hodgkin's disease with a possibility of a malignant potential and others proposed that the lymphoid masses were of a hamartomatous nature. Three histologic variants and two clinical types of the disease have been described. The disease may occur in almost any area in which lymph nodes are normally found. The most common locations are thorax (63%), abdomen (11%) and axilla (4%). We report two separate histologic types of Castleman's disease which were rare in the literature, mimicking sigmoid colon tumor and Hodgkin lymphoma. The diagnostic and therapeutic aspects of this rare entity is discussed.

Laparoscopic enucleation of giant liver hemangioma.

The cavernous hemangioma is the most common benign tumor of the liver. It usually becomes symptomatic as it reaches a certain size. A 49-year-old man was admitted with a 1-year history of epigastric pain, which was not relieved by regular analgesic intake, and nausea. The results of physical examination, routine laboratory tests, and upper gastrointestinal tract endoscopy were normal. Ultrasonography showed a 10-cm mass in the left hepatic lobe. Magnetic resonance imaging (MRI) showed a 90-mm hemangioma at left hepatic lobe. Selective celiac arteriogram was performed, and polyvinyl alcohol particles were used as an embolizing agent. After the embolization, the patient underwent laparoscopic enucleation of the liver hemangioma. No blood transfusion was needed during the operation. The operative time was 75 min. The patient was allowed to take a clear liquid diet on the postoperative day 1. The postoperative course of the patient was uneventful, and he was discharged on the postoperative day 2. Enucleation is the best surgical technique for the management of symptomatic giant hemangiomas. It can be performed with no mortality or morbidity, with preservation of all normal liver parenchyma. Enucleation also has been associated with significantly fewer intraabdominal complications than anatomic resection. The laparoscopic approach for enucleation requires patience and careful dissection to prevent bleeding. In conclusion, laparoscopic enucleation of hemangiomas is safe and easy to perform in selected cases.

Effect of growth hormone treatment on the healing of left colonic anastomoses in protein-malnourished rats.

BACKGROUND: Malnutrition is known to affect wound healing but it is not known with certainty whether or not postoperative hyperalimentation can reverse this defect. The present study was designed to examine the effects of recombinant human growth hormone (hGH) on left colonic anastomoses in malnourished rats. METHODS: Experimental animals were allocated randomly into four groups. In groups 1 and 2 animals were fed with normal diet for 10 days before surgery. In groups 3 and 4 animals were fed with a low-protein diet. Left colonic anastomoses were performed in all animals. Following surgery, rats in groups 1 and 3 received hGH whereas rats in groups 2 and 4 were injected with saline as control. Bursting pressure and hydroxyproline levels on day 4 after operation were used to determine anastomotic healing. RESULTS: Bursting pressure was lower in the malnourished rats than those fed with normal diet (P< 0.05). Bursting pressure was higher in normally fed rats which were given hGH. No significant differences could be noted between malnourished control rats and those receiving hGH. CONCLUSION: These results suggest that hGH strengthened the left colonic anastomoses in rats fed a normal diet, but could not reverse the negative effects of malnutrition on colonic anastomoses.