LAPAROSCOPIC NISSEN ROSETTI FUNDOPLICATION IN TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE: EVALUATION OF LONG TERM CLINICAL OUTCOMES AND QUALITY OF LIFE.

The aim of this study is to evaluate outcomes of Nissen-Rossetti fundoplication in-terms of objective measures and quality of life evaluation instruments. For the period in observation, the chronic GERD patients, who had undergone LNRF surgery, were evaluated. The long-term outcome was assessed by subjectively comparing the preoperative and postoperative symptoms and Gastroesophageal reflux-Health related quality of life index. As an objective assessment of the pathological reflux, patients underwent 24-hour pH monitoring in the preoperative and postoperative period. Thirty-two patients, who met the criteria and volunteered to participate, were included in the study. The median postoperative follow-up period for the patients was 28±7.92 (16-52) months. A significant increase was observed in the quality of life scores in the postoperative period when compared to the preoperative period (p=0.001) and the DeMeester scores have decreased significantly (p=0.001). The postoperative dysphagia was observed even in the long term in most of the patients, without having a significant effect on the quality of life. In the treatment of gastroesophageal reflux disease, laparoscopic Nissen Rossetti fundoplication is an effective and successful method in achieving the desired outcome such as preventing pathological reflux, relieving the symptoms and improving the quality of life in the long term.

A prospective comparative study of the efficacy of conventional Lichtenstein versus self-adhesive mesh repair for inguinal hernia.

PURPOSE: Lichtenstein repair has been the gold standard in inguinal hernia surgery. The aim of this study was to investigate the role of mesh fixation in terms of postsurgical chronic pain and recurrence. METHODS: Sixty patients with primary inguinal hernias were treated between March 2007 and December 2008. Thirty patients underwent conventional Lichtenstein repair while a self-adhesive mesh was used for the second group. The primary outcome parameters were the rate of recurrence and chronic pain. The operating time, postoperative pain, complications, and time when patients returned to work were recorded. RESULTS: Fifty-one patients completed the survey. Early pain scores were lower in the self-adhesive mesh group. The main advantage of the self-adhesive mesh was the shorter operating time (23.70 ± 5.57 vs 36.90 ± 11.36, P = 0.006). Both techniques were almost identical in terms of long-term chronic pain (P = 0.294), and the rates of recurrence at the end of a median of 31 months' follow-up were identical. CONCLUSION: Self-adhesive mesh repair of inguinal hernias is superior to the conventional Lichtenstein method in terms of shorter operative time and less pain in the early postoperative period. The rates of chronic pain and recurrence are similar with the suture-fixed repairs.

Cleft lift procedure for sacrococcygeal pilonidal disease.

PURPOSE: The surgical treatment of sacrococcygeal pilonidal disease varies widely. This study reports outcomes of cleft lift procedure combined with pit excision performed both in primary and recurrent pilonidal disease. METHODS: A total of 76 consecutive patients with primary or recurrent pilonidal disease who received cleft lift procedure or combined (cleft lift with pit excision) procedure in our clinic between March 2005 and May 2007 were investigated prospectively. Rate of postoperative complications and disease recurrence were the primary outcomes. RESULTS: Mean follow-up was 16.4 months (SD 7.0, range 5-34). The most common early postoperative complications were minor wound dehiscence (11 patients, 14.5 percent), followed by infection (10 patients, 13.2 percent), and wound break (4 patients, 5.3 percent). One recurrence (1.3 percent) was observed during the follow-up. CONCLUSIONS: The results of the current study supported that cleft lift procedure fulfills the requirements of an ideal operation for pilonidal disease. The cleft list procedure was a relatively simple procedure that was easy to learn, to teach, and perform under either spinal or local anesthesia. The procedure can be performed as a "day-surgery" procedure with low postoperative morbidity, acceptable time to return to work, and low recurrence rate.

Xanthogranulomatous inflammation of the colon: a rare cause of cecal mass with bleeding.

Xanthogranulomatous inflammation is a well-defined disease most frequently reported in the kidney and gallbladder. The occurrence of this disease in the colon is extremely rare, with only five cases of appendix vermiformis involvement in the literature. Its clinical importance is that it can be misinterpreted as a malignant process clinically and intraoperatively as well as in the imaging studies. In this report, a 57-year-old patient presented with a cecal mass that caused recurrent lower gastrointestinal bleeding and anemia, mimicking colon cancer. This is the first report of this lesion involving the cecum with typical macroscopic and microscopic features but with atypical clinical symptoms and findings.

[Non-operative management of blunt hepatic trauma]. / Künt karaciger travmalarina konservatif yaklasim.

BACKGROUND: Blunt hepatic trauma is frequently seen, particularly as a result of traffic accidents. Given that surgical therapy may have high rates of morbidity and mortality, a selected group of patients may can benefit from conservative management. We herein present, a group of patients with blunt hepatic trauma who were managed without any invasive diagnostic tools and / or surgical intervention. METHODS: Nineteen hemodynamically stable patients (9 males, 10 females; mean age 46,6; range 19-73 years) with blunt hepatic trauma were included in the study. Vital signs, hemodynamic parameters, liver function tests, need for transfusion, hospital stay and results of radiological tests were recorded as well as demographic characteristics. Classification of injury was done according to the American Association for the Surgery of Trauma's Organ Injury Scaling System. RESULTS: Nineteen patients had radiologically-proven liver injury. Nine patients had grade I injury, five had grade II, two had grade II and three had grade IV injuries. Twelve patients required blood transfusions. Fourteen patients had mild elevation of transaminases while the remaining five were completely normal. Mean hospital stay was 7.6 days. Blunt trauma was associated with a large abdominal wall hernia in one patient; the defect was repaired laparoscopically three months later. No patient underwent surgery due to the failure of conservative management and there was no death. CONCLUSION: For blunt hepatic trauma patients, non-operative management may be the initial therapy if haemodynamic stability can be maintained. The decision for surgical intervention should be given according to the presence of associated intraabdominal injuries. Liver injury score of patients is not as important as the hemodynamic status for determining conservative management.

Santulli enterostomy revisited: indications in adults.

BACKGROUND: Surgical patients frequently need some type of intestinal stomas for a wide spectrum of disorders. Maintaining effective and enough decompression of gastrointestinal tract, securing distal bowel segments and anastomosis are the primary goals of ostomy formation as well as providing a minimum complication rate of closure or "take-down". METHOD: In this report, we present five adult patients who were operated for some kind of intestinal disease and required enterostomy. We preferred Santulli type of enterostomy which was formerly used by pediatric surgeons. In this technique, the proximal afferent bowel is fashioned into a stoma and anastomosed side-to-end with double layer sutures into the distal efferent bowel. RESULT: One of the five patients died of systemic problems, other four did well in terms of surgical outcome of the stoma. CONCLUSION: We concluded that; although indications are limited, Santulli enterostomy can be performed in adult patients as effective as pediatric age group, particularly for its advantages in early restoration of intestinal continuity and diminished risk for post-closure complications.

Three-field lymph node dissection in the treatment of thoracic esophageal carcinoma: the Turkish experience.

The role of extended lymphatic dissection on the prognosis and outcome of thoracic esophageal carcinoma is still controversial. The aim of this study was to determine the impact of three-field lymphatic dissection on the survival and recurrence rates of patients with thoracic carcinoma of the esophagus. Forty-six patients with primary squamous cell carcinoma of the thoracic esophagus underwent esophagectomy with three-field lymphatic dissection between 1992 and 2003. Recurrence and survival rates were examined as well as complications. Overall survival for the patients was 45.6 months and 5-year survival rate was 56%. Five-year survival rates for patients with Stage 2A, 2B, 3 and 4 were 68%, 0%, 53% and 33%, respectively. There was no Stage 1 patient. Mean disease-free survival was 41.4 months. Sixty three percent of patients had node-negative disease (5-year survival rate, 68.9%) and 37% had nodal metastases (5-year survival rate, 33.7%) (P = 0.002). Surgical morbidity was seen in 35 patients (76.1%). Conclusively, lymph node involvement in patients with thoracic esophageal carcinoma is the major determinant of prognosis and survival. Extended lymphatic dissection provides higher disease-free and overall survival rates and our study revealed the highest survival rate for thoracic esophageal carcinoma, to best of our knowledge.

Effect of hypercholesterolemia on experimental colonic anastomotic wound healing in rats.

AIM: To evaluate the mechanical and biochemical parameters of colonic anastomotic healing in hypercholesterolemic rats. METHODS: Sixty rats were divided into two groups of 30 each according to their dietary regimens. The test group was fed with a high cholesterol-containing diet for two months while the control group had standard diet. These two groups were further divided into three subgroups consisting of ten rats each. After hypercholesterolemia was established, left colon resection and anastomosis were performed in both groups and samples from liver and abdominal aorta were taken to evaluate the systemic effects of hypercholesterolemia. Anastomotic wound healing, blow-out pressures and tissue hydroxyproline levels were evaluated. RESULTS: The test group had a significant weight gain in two months. Microscopic examination of the abdominal aorta revealed no atherosclerotic change in none of the groups, but liver tissue specimens showed significant steatosis in the test group. Tissue hydroxyproline levels and anastomotic blow-out pressures were significantly lower in the test group than in the controls. CONCLUSION: Hypercholesterolemia not only increases hydroxyproline levels and blow-out pressures but also worsens anastomotic wound healing.

Endoscopy-assisted resection for multiple polyps of the small intestine in Peutz-Jeghers syndrome: a father and daughter story.

Peutz-Jeghers syndrome is an infrequently encountered disease with potential complications including bleeding, intestinal obstruction, intussusception, and malignant transformation. We report on two patients, father and daughter, with Peutz-Jeghers syndrome who were admitted to hospital with similar complaints of abdominal pain. The father was 37 years old and the daughter was 17. Physical examination and laboratory tests revealed small intestinal intussusception in both patients. In the daughter, the intussuscepted segment was resected. An electrosurgical snare was also used for enteroscopic excision of multiple jejunal and ileal polyps. In the father, two 4-cm polyps were surgically resected while an enteroscopic surgical snare was used for polyps of smaller size. Both patients were discharged on postoperative day 7.

Laparoscopic bilateral hernia repair using fibrin sealant: technical report of two cases.

Minimally invasive surgery is widely used in hernia repair given its advantages such as minimal disturbance to the surrounding tissues, shorter hospital stay, and promising long-term results. Efforts are still being made to make this minimally invasive procedure even more minimal. New tissue adhesives avoid the use of foreign materials and the postoperative pain that might be attributed to staples. We present the first two cases of bilateral inguinal hernia repair performed with a totally extraperitoneal procedure using fibrin sealant instead of staples for the fixation of the mesh.

Surgical management of enoxaparin- and/or warfarin-induced massive retroperitoneal bleeding: report of a case and review of the literature.

A 70-year-old man on enoxaparin and warfarin sodium therapy due to pulmonary embolism was admitted for evaluation of a sudden, sharp pain in the left inguinal region. Physical examination revealed a 5 x 10 cm tender mass. Abdominal ultrasound showed a 9 x 9 x 10 cm left retroperitoneal hematoma. INR was 2.1, and anticoagulation therapy was discontinued. A regimen of supportive therapy (vitamin K, fresh frozen plasma and blood transfusion) was started, but the hemorrhage continued to enlarge, up to 9 x 10 x 20 cm, and the patient experienced a significant deterioration in his overall status. He underwent an urgent laparotomy and the hematoma was evacuated. A retroperitoneal abscess developed during the postoperative period which was drained percutaneously. He was discharged on postoperative day 33 with no further complaints. This case demonstrates the importance of surgical therapy in the treatment of spontaneous retroperitoneal hemorrhage caused by anticoagulant therapy.

Effect of calcitonin gene-related peptide on anastomotic healing in the presence of endotoxin.

BACKGROUND: Intestinal anastomotic healing is a complex procedure in which several mediators, cytokines and other substances play roles, as well as calcitonin gene-related peptide (CGRP). CGRP is capable of stimulating DNA synthesis and cell proliferation in endothelial cells by increasing vasodilatation and inflammatory response and promoting epithelial, vascular and mesothelial cell proliferation. This study was undertaken to investigate whether CGRP has a beneficial effect on intestinal anastomotic healing, even in septic conditions. METHODS: Four groups of 10 rats were administered normal saline (0.5 mL), lipopolysaccharide (LPS) (0.5 mg/kg), CGRP (0.5 mL 6.5 x 10(-10) mol/L) and LPS + CGRP (0.5 mg/kg + 0.5 mL 6.5 x 10(-10) mol/L) via intraperitoneal route, respectively, 24 h prior to operation and postoperatively. All rats underwent ileo-ileal end-to-end anastomosis. Anastomotic bursting pressure and tissue hydroxyproline levels were measured on postoperative day 7. RESULTS: Calcitonin gene-related peptide was found to have positive effects on both parameters of healing. The LPS-injected group showed intestinal anastomotic healing disorder suggesting impaired collagen production, which showed improvement after CGRP administration. CONCLUSIONS: Calcitonin gene-related peptide increases anastomotic wound healing in experimental intestinal anastomosis in the presence of endotoxin.

Laparoscopic "second-look" in the management of mesenteric ischemia.

Mesenteric ischemia is a major cause of mortality in surgery. Despite the advances in medicine, considerable number of patients undergoes reoperations for a better assessment of intestinal viability. Although great majority of these second-look operations are "negative explorations," progressive nature of this devastating disease pushes surgeons to re-explore the abdomen. This study compares open and laparoscopic "second-look" procedures in patients with mesenteric ischemia. In the first group (n = 41), abdomen was closed and second-look laparotomy was performed to 23 patients. In the second group (n = 36), a 10-mm trocar was inserted before closing the abdomen and second-look intervention was performed by a telescope to 23 patients. Sixteen of relaparotomies in the first group (70%) revealed nothing and were unnecessary. Two patients (8%) in the laparoscopy group needed re-resection while 20 patients (87%) were rescued from unnecessary laparotomies. Conclusively, patients with mesenteric ischemia are "ill enough" to deserve the "minimal invasion" spirit of laparoscopic surgery.

Positive effect of low molecular weight dextrans on the early graft function.

This study evaluates the effect of the low molecular weight dextrans as a perfusion solution on early graft function of twenty living donor kidneys. Ten kidneys were perfused with +4 degrees C Ringer lactate after nephrectomy while other ten with +4 degrees C Ringer lactate + 10% Dextran. Immediate and delayed kidney function, blood creatinine, postoperative hemodialysis requirement, Doppler US and renal scintigraphy, third month graft survival and number of removed grafts were examined postoperatively as well as kidney biopsies. No statistical difference was found between the groups regarding the post-transplant ATN period. But the microscopic examinations demonstrated less damage-more function in Ringer lactate+Dextran group compared to Ringer lactate alone.

Huerthle cell neoplasms of the thyroid: predicting malignant potential.

OBJECTIVE: Assessment of malignancy criteria in Huerthle cell neoplasm. METHODS: This study intends to review retrospectively the patients who were operated for Huerthle cell neoplasia at Gazi University, Department of General Surgery between January 1986 and October 1999. Pathological specimens from 63 patients (20 males and 43 females) were investigated in this study, 48 of which revealed Huerthle cell adenoma and 15 revealed Huerthle cell carcinoma. The mean age of the patients with Huerthle cell adenoma was 40.7+/-1.59 yr while it was 51.3+/-1.83 yr in patients with Huerthle cell carcinoma. Mann-Whitney U and Chi-square tests were used for statistical analysis. RESULTS: . Fifty-two of the 63 patients had fine needle aspiration (FNA) biopsy prior to operation, 49 of those were reported to have suspected Huerthle cell neoplasia (HCN) and three had suspected Huerthle cell carcinoma (HCC). The sensitivity of FNA for HCN was 20 %, specificity was 100 %, positive predictive value was 100 % and negative predictive value was 76 %. For all patients, peroperative frozen section (FS) biopsy was examined. Fifty-nine of the FS specimens revealed HCN and four revealed HCC. The sensitivity, specificity, positive predictive value and negative predictive value of FS biopsy were 27 %, 79 %, 28.5 % and 77.5 %, respectively. In this retrospective study, there was a statistically significant correlation between malignancy and the size of the tumor (P<0.05) according to Chi-square test, and also a statistically significant correlation between malignancy and the age of the patient (P<0.05) according to Mann-Whitney U test. CONCLUSIONS: In cases where FS and FNA biopsies cannot adequately define the benign or malignant behaviour of the tumor, the age of the patient and the diameter of the tumor must be taken into consideration for accurate surgical strategy. Particularly for 50 year-old and elderly, incidence of malignancy is statistically significant without considering sex of the patient.

Bovine and PTFE vascular graft results in hemodialysis patients.

Purpose. There are many reports of patency periods, failure rates, thrombosis and infection attacks connected with vascular grafts. In this article, the results of polytetrafluoroethylene (PTFE) and Bovine grafts were compared in a forty-four month period. Methods. 61 vascular grafts (29 PTFE, 32 bovine) were placed in 49 patients. The grafts were compared in different ways, such as survival, complication rates and placement area using life survey analysis. Results. Mean survival time was 17 mo (SE +/- 2.8) for PTFE grafts and 11 mo (SE +/- 1.1) for bovine grafts. A failure rate of 34% due only to graft complications were found in PTFE and 25% in bovine grafts. All graft complications were seen in the first year. Comparison of the cumulative survival rates of the groups were found to be insignificant during the study period and the first year ( p>0.05). Regardless of the type, there was no signif-icant difference between the grafts placed in the forearm and the grafts in the thigh (p>0.05). Conclusions. There is no survival difference between PTFE and bovine grafts. First year of the grafts is important for developing complications.

Role of endogenous endothelin peptides in intestinal ischemia-reperfusion injury in rats.

In this study, the effects of BQ123 (an ET(A) receptor antagonist), bosentan (a nonselective ET(A)-ET(B) antagonist), and phosphoramidon (an endothelin converting enzyme inhibitor) were investigated on intestinal mucosal lesion formation and changes in tissue PGE2 and LTC4 levels due to intestinal ischemia-reperfusion (I/R) injury in rats. Following 30 min of ischemia, the substances were given via the inferior caval vein, and 10 min later the intestine was subjected to reperfusion for 30 min. The intestinal specimens were evaluated both microscopically and the tissue PGE2 and LTC4 levels were obtained for each group. The histopathologic examination revealed a significant reduction in tissue injury in both BQ123 and phosphoramidon pretreated groups compared with the control group. Bosentan, on the contrary, did not decrease the injury. The pharmacologic examination revealed a significant reduction of PGE2-like activity in both BQ123 and phosphoramidon pretreated groups, compared with the control group, while LTC4-like activity remained unchanged except for an increase in the bosentan pretreated group.

Cystic lymphangioma of the spleen mimicking hydatid disease.

Cystic lymphangioma is a very rare condition generally accepted to be the result of a developmental malformation of the lymphatic system. Usually seen in children, it occurs infrequently in adults. The neck (75%) and axillary regions (20%) are the most common locations of lymphangioma, but it can occur in the retroperitoneum, mediastinum, mesentery, omentum, colon, pelvis, groin, bone, skin, scrotum, and spleen. We present a cystic lymphangioma of the spleen with emphasis on its rarity in this site and problems of differential diagnosis with hydatid disease.