Evaluation of activated charcoal and lipid emulsion treatment in model of acute rivaroxaban toxicity.

AIM: Reducing or reversing the toxicity effects of new oral anticoagulants is an important question.The purpose of the present study is to evaluate the effect of lipid emulsion (LE) and Activated Charcoal (AC) therapy on the intoxication of rivaroxaban, on mice. METHODS: Adult male Balb/c mice weighing approximately 30g were used in the study. Seven groups were assigned, with six mice in each group. Groups were defined; given only rivaroxaban, given only LE, given only AC, after the administration of rivaroxaban LE applied group in the 1st hour, after the administration of rivaroxaban LE applied group in the 3rd hour, after the administration of rivaroxaban AC applied group in the1st hour, after the administration of rivaroxaban AC applied group in the 1st hour and LE applied group in the 3rd hour. PT and Anti-Factor Xa activity were measured in all blood samples from subjects. RESULTS: A statistically significant difference was found when all groups were compared in terms of mean PT values and Anti-FactorXa values. However, no statistically significant difference was found in the mean PT and Anti-FactorXa values when only rivaroxaban administrated group and after the administration of rivaroxaban LE and/or AC applied groups were compared one to one. No deaths occurred in groups during the observation. CONCLUSION: Although the administration of either AC or LE alone or in combination resulted in a decrease in the mean values of PT and anti-Factor Xa, in case of rivaroxaban toxicity, but one-to-one comparison of the groups was not statistically significant.

The effects of preoperative oral antibiotic use on the development of surgical site infection after elective colorectal resections: A retrospective cohort analysis in consecutively operated 90 patients.

PURPOSE: The influence of oral antibiotic use together with mechanical bowel preparation (MBP) on surgical site infection (SSI) rate, length of hospital stay and total hospital costs in patients undergoing elective colorectal surgery were evaluated in this study. METHODS: Data from 90 consecutive patients undergoing elective colorectal resection between October 2006 and September 2009 was analyzed retrospectively. All patients received MBP. Patients in group A were given oral antibiotics (a total 480 mg of gentamycin, 4 gr of metronidazole in two divided doses and 2 mg of bisacodyl PO), whereas patients in group B received no oral antibiotics. Exclusion criteria were emergent operations, laparoscopic operations, preoperative chemoradiotherapy, intraoperative colonoscopy prior to the creation of an anastomosis or antibiotic use within the previous 10 days. SSI, length of hospital stays and total hospital charges were evaluated. RESULTS: Patients in both study groups, group A (n = 45) and group B (n = 45), were similar in terms of age, BMI, diverting ileostomy creation, localization and stage of the disease. Patients receiving oral antibiotics demonstrated a lower rate of wound infections (36% vs. 71%, p < 0.001), shorter hospital stay (8.1 ± 2.4 days vs. 14.2 ± 10.9 days, respectively, p < 0.001) and similar rates for anastomotic leakage (2% vs. 11%, p = 0.20). The mean ± SD total hospital charges were significantly lower in Group A (2.699 ± 0.892$) than that in Group B (4.411 ± 4.995$, p = 0.029). CONCLUSION: Preoperative oral antibiotic use with MBP may provide faster recovery with less SSI and hospital charges.

Single Incision Laparoscopic Cholecystectomy by Using a 2 mm Atraumatic Grasper without Trocar.

Purpose. We present our experience in single incision laparoscopic cholecystectomy by using a grasper directly without using a trocar in five patients. Methods and Results. The technique involves the use of Karl Storz 27290F grasper in order to perform gallbladder retraction in single port cholecystectomy. The grasper was introduced directly into the skin through abdominal wall without using any trocar and used to mobilize gallbladder whenever needed during surgery without causing any perforation or leakage of the gallbladder. There were no intraoperative and postoperative complications in 5 patients with the advantages of shorter operation time and almost invisible postoperative skin scar formation. Conclusion. We claim that the use of this instrument in SILS surgery might be advantageous than the conventional placement of sutures for the gallbladder mobilization.

The value of copper and zinc levels in hernia formation.

BACKGROUND: A defect in collagen metabolism is suspected to be one of the factors responsible for hernia formation. Lysyl oxidase is a copper-dependent enzyme in the process that provides for the structural integrity of collagen molecules, while zinc is essential for tissue maintenance. MATERIALS AND METHODS: In a prospective fashion, copper and zinc levels were measured in plasma and tissue specimens obtained from indirect (n=23), direct (n=20) and incisional hernia patients (n=19) and from healthy controls (laparoscopic cholecystectomy patients, n=15) by enzymatic colorimetric analysis. RESULTS: Groups were similar in age, comorbid diseases and body mass index. Whereas plasma levels of Cu and Zn in hernia and control patients were similar, and tissue levels were significantly lower in all hernia groups (especially the incisional hernia group) compared to controls (P<0·001). The incisional hernia group had significantly lower tissue copper levels than direct hernia patients and lower zinc levels than indirect hernia patients. CONCLUSIONS: Patients with all types of hernia, especially those with incisional hernias, have significantly lower tissue copper and zinc levels than control patients, despite having similar plasma levels. This finding might reflect excessive consumption or dysfunction of lysyl oxidase as playing a role in the aetiology of hernias.

Torsion of the primary epiploic appendagitis: a case series and review of the literature.

BACKGROUND: Differential diagnosis and appropriate treatment of epiploic appendagitis (EA) is a dilemma for general surgeons because of nonspecific signs and symptoms. METHODS: Twelve patients (3 women and 9 men, average age 40 years, range 18-82 years) who were diagnosed as having EA upon presenting to the emergency department or at the time of discharge between April 2002 and September 2008 were included. RESULTS: The major presenting symptom was abdominal pain. Physical examination revealed well-localized tenderness in all cases (n = 12); in addition, rebound tenderness and distention were also observed. Laboratory blood tests were normal except for 4 patients who had leukocytosis. Seven cases were diagnosed by an abdominal computed tomography scan. Five patients required surgical intervention, whereas the remaining did not. CONCLUSIONS: Surgeons should be aware of this self-limiting disease that mimics many other intra-abdominal acute conditions. An abdominal computed tomography scan has a significant role in accurate diagnosis of EA before surgery to avoid unnecessary surgical interventions.

Occult intrabiliary rupture of hydatid cysts in the liver.

The aim of this study was to investigate the effects of various surgical modalities directed at the cavity of hydatid cysts in patients with occult intrabiliary rupture. In this respect, 324 patients with hydatid cyst of the liver operated on during 1983-2003 were analyzed; among them, 39 patients with occult intrabiliary rupture were included in the study. Clinical symptomatology, physical examination, laboratory findings, results of imaging studies, the localization and size of the cyst, and operative findings were reviewed. Twelve patients had complications, and there was no mortality. The most common complication was bile fistula. The average postoperative hospital stay was 7.0 +/- 3.8 days for patients with omentoplasty and 6.0 +/- 2.5 days for those who underwent cavitary drainage. For patients who do not have bile-stained cystic fluid, the utilization of scolicidal agents is appropriate. Although the opening of the duct is sutured when it is identified, the risk of biliary fistula is not clearly correlated with this approach. In such cases, omentoplasty provides a good alternative to cavitary drainage.

Unusual locations of hydatid disease and surgical approach.

BACKGROUND: Hydatid disease is an endemic parasitic disease of the Mediterranean countries. Although the liver is the most commonly involved organ, the disease can be seen anywhere in the body. In the present study, we present our experience with uncommonly located hydatid disease diagnosed and treated between 1983 and 1999 in the Sixth Surgical Department of Ankara Numune Training and Research Hospital, Ankara, Turkey. METHODS: Forty-nine patients with unusually located hydatid disease were retrospectively analysed. There were 21 men and 28 women in the present series. Of those, 26 patients were harbouring both hepatic and extrahepatic cysts, while 23 had only extrahepatic cysts. Peritoneal cavity, spleen, retroperitoneum, thyroid gland, anterior abdominal wall, thigh, kidney, presacral space and pancreas were the organs or tissues involved in the cases. Spleen and peritoneal cavity were the two most frequent locations in the present series. RESULTS: Partial or total cystectomy with or without tube drainage or omentopexy was the operation of choice for hydatid cyst of the peritoneal cavity. Splenectomy was performed for splenic hydatidosis. Mean postoperative stay was 7 days (4-23). Three diaphragmatic and one inferior vena cava lacerations occurred during operations that were repaired successfully in the same sessions. No mortality occurred in the present series. CONCLUSION: Hydatid disease can affect any organ or area throughout the body and suspicion of this disease should be justified in patients presenting with a cystic mass in endemic areas.

Use of laparoscopic splenectomy in developing countries: analysis of cost and strategies for reducing cost.

BACKGROUND: In general, laparoscopic surgery is more expensive than open surgery. However, recent reports showed lower overall cost. PATIENT AND METHODS: Fourteen patients underwent laparoscopic splenectomy (LS) and 15 patients open splenectomy (OS). Patients were evaluated with regard to blood loss, complication rate, length of hospital stay, operative time, presence of accessory spleens, hospital cost, and total cost. For the OS group, there was no laparoscopic instrument cost, and the total cost was equal to the hospital cost. In the LS group, total cost was calculated by adding the hospital cost to the cost of laparoscopic instruments. RESULTS: The postoperative hospitalization was shorter in the LS group than the OS group (3.4 vs. 7.5 days), but the operating time was significantly longer for the LS group. The mean hospital cost was calculated as US $1,055 in the LS group and $1,664 in the OS group. The overall total cost was $1,664 for the OS group and $2,064 for the LS group. In the LS group, less morbidity and shorter postoperative hospital stay resulted in lower hospital cost. CONCLUSION: The cost for laparoscopic instruments is the main factor responsible for the high total cost of LS. Resterilization of disposable laparoscopic instruments is feasible and a more economic way of treatment compared with splenectomy with totally disposable laparoscopic instruments and has costs comparable to those of open surgery.

Hemodynamic changes during gaseous and gasless laparoscopic cholecystectomy.

PURPOSE: The main disadvantage of gaseous laparoscopic surgery is the need for CO(2) insufflation and the elevation of intra-abdominal pressure. Gasless laparoscopic surgery is an alternative to gaseous laparoscopic surgery, which avoids the hazardous effects of pneumoperitoneum. This study was conducted to investigate the hemodynamic effects of pneumoperitoneum and to compare gasless and gaseous laparoscopic cholecystectomy on a hemodynamic basis. METHODS: The gasless laparoscopic procedure uses an electromechanical retractor system to lift the abdominal wall. We performed 20 gaseous and 11 gasless laparoscopic cholecystectomies in a collective total of 31 patients with symptomatic gallstones. The mean arterial pressure, heart rate, end diastolic index, systemic vascular resistance index, cardiac index (CI), ejection fraction (EF), and stroke index (SI) values were monitored noninvasively by thoracic electrical bioimpedance. RESULTS: In the gaseous group, statistically significant changes were detected in CI, EF, and SI values after insufflation as compared to the values before pneumoperitoneum. In the gasless group, only minimal changes were detected in the SI values, which were not significant. CONCLUSION: Gasless laparoscopy has little effect on the hemodynamic parameters of patients and provides an alternative to the gaseous technique in selected cases.

The effect of methylene blue on peritoneal adhesion formation.

BACKGROUND/AIMS: Postoperative adhesions following abdominopelvic surgery may cause significant morbidity. In this study, the effect of different doses of methylene blue in the formation of adhesions and the role of allopurinol in revealing the possible mechanism of action was evaluated. METHODS: Seventy five male Wistar-Albino rats weighing 200g-220g. were divided into five groups of 15 rats each. After laparotomy, cecal serosal abrasions were performed. In Group I, 1ml of saline was administered intraperitoneally, while Group II, III and IV were given 1mg/kg, 5mg/kg and 9mg/kg of intraperitoneal methylene blue respectively. In Group V after 1 ml of saline administration at surgery, allopurinol 30 mg/kg/ day was administered postoperatively for 14 days. On day 14, laparotomies were repeated. Adhesions were graded and tissue samples were taken from incisions and adhesions. Hydroxyproline contents representing adhesions were measured quantitatively. RESULTS: Low dose methylene blue (Group II) caused inhibition of adhesion formation when compared with that of other groups (p<0.05). With a higher dose (Group III), this effect disappeared and methylene blue actually induced adhesion formation (p<0.05) at the highest dose (Group IV). Allopurinol treatment (Group V) also provoked adhesion formation when compared with Group I (p<0.05). CONCLUSIONS: Methylene blue has diverse effects on postoperative adhesions in a dose-dependent manner. While with low doses there is evidence of inhibition, it promotes adhesion formation at higher doses. As allopurinol also provokes adhesion formation, it is thought that the preventive role of methylene blue may not be due to its free oxygen radical inhibitor effect but the mechanism has yet to be clarified.