Ischemia-reperfusion injury in the liver during renal transplantation: does perfusion solution play any role?

The effect of ischemia-reperfusion (I/R) injury within a transplanted kidney has not been reported on the liver as a remote organ. One hypothesis is that there is no difference between kidney perfusion solutions regarding antioxidants in liver after an I/R injury. We used four pigs with Ringer's lactate (RL); four with university of Wisconsin (UW); and two in a control (C) group. A liver parenchymal biopsy was obtained before renal artery/vein solution clamping for 20 minutes. Either RL or UW solutions were infused through arterial cannulas for 20 minutes as previously described elsewhere. For the sham group, we used 0.9% NaCl. After reperfusion for 20 minutes, we obtained a second liver parenchymal biopsy. Measurements of superoxide dismutase (SOD), glutathione peroxidase (GP-x), and malondialdehyde (MDA) levels were compared using paired student t tests within groups and analysis of variance between groups. The results were expressed as mean values +/- SEM with P < .05 accepted as significant. Although GP-x, SOD, and MDA decreased after ischemia-perfusion-reperfusion injuries in all groups, except MDA in UW and SOD, and MDA in C groups; only the MDA for C was significant (P = .04) Comparing the groups, GP-x (P = .01) and MDA (P = .003) levels after ischemia-perfusion-reperfusion were significant while changes in SOD levels did not show any difference (P > .05). In a kidney transplantation model, the liver was affected during the ischemia-perfusion-reperfusion process as evidenced by antioxidant enzymes. The pathophysiology and clinical importance of this phenomenon requires further study. Comparing the perfusion solutions, no difference was found between RL and UW regarding their effects to decrease renal I/R injury on the liver in pigs.

Persistent mediastinal and axillary lymph node tuberculosis in a renal transplant patient with successful outcome.

Tuberculosis is an opportunistic infection that carries substantial morbidity and mortality in renal transplant recipients. We report here about a 21 year-old man with a living related renal transplant from his mother who developed persistent extra-pulmonary tuberculosis. The disease showed aggressive invasion to the axillary and mediastinal regions with abscess formations, despite standard antituberculosis treatment. During the course of the disease, immunosuppressive therapy was stopped, and the patient received extraordinary doses of multiple antituberculosis drugs. The patient then showed an uneventful course with good clinical and radiological responses.

Effects of perfusion solutions on kidney ischemia-reperfusion injury in pigs.

During ischemia-reperfusion, free oxygen radicals which directly affect renal cells may cause delayed graft function. We investigated whether there was a difference regarding antioxidant enzyme content between use of Ringer's lactate (RL) versus University of Wisconsin (UW) perfusion solutions in kidney transplantation. Ischemia was achieved by clamping the renal pedicle for 20 minutes followed by perfusion with either solution for 20 minutes and reperfusion for another 20 minutes. A parenchymal biopsy was taken before and after the ischemia, perfusion, and reperfusion (IPR) process. The levels of superoxide dismutase (SOD), glutathione peroxidase (GPx), and malondialdehyde (MDA) were investigated in the biopsy specimens. We used paired t tests within groups and t tests for comparisons between groups. The results were expressed as mean values +/- SEM with P < .05 accepted as statistically significant. After IPR, SOD, GPx, and MDA were decreased in all groups: only GPx (P = .001) and MDA (P = .04) for the RL group and SOD (P = .001) and MDA (P = .05) for the UW group were statistically significant. In the control group, we did not observe any difference (P > .05). Comparisons between groups did not reveal differences (P > .05). In our study, no difference was observed between RL and UW regarding their effects on antioxidant enzymes following renal I/R injury in pigs. More investigations are needed to evaluate graft function in this setting.

Do we need to use subcutaneous suture for pilonidal sinus treated with excision and simple primary closure?

OBJECTIVE: Pilonidal sinus (PS) is a chronic intermittent disease. There are numerous surgical treatment procedures that have been previously reported, yet none have been proved to be ideal. The main issues concerning the surgical treatment of PS are simplicity and cost-effectiveness. This study is designed to research the possibility of decreasing operation costs in the excision and simple primary closure technique of PS by omitting subcutaneous suture usage. MATERIALS AND METHODS: 152 male patients with chronic PS were included in the study. All patients were treated with excision and simple primary closure technique and randomized into two groups. Group-I (n = 74) received subcutaneous closure with 2/0 polyglactin sutures, but Group-II (n = 78) did not. Wound edges were re-approximated by using deep interrupted matress 0 no polypropylene sutures in both groups. RESULTS: In Group-I; overall 7 (9.5%) early complications were noted; 2(2.7%) wounds broke down and 5 (6.7%) experienced superficial wound infections. Any late wound complications were noted. A total of 98 polypropylene and 104 polyglactin sutures were used. In Group-II; overall 5 (6.4%) early wound complications were noted; 3 (3.8%) had wound dehiscence and 2 (2.6%) developed superficial wound infections. Also, 1 (1.3%) late wound complication (wound dehiscence) occurred. Overall 104 polypropylene sutures were used. CONCLUSION: Excision and simple primary closure is a simple and cost effective surgical procedure in the treatment of PS. Omitting the use of subcutaneous sutures makes the procedure simpler and decreases the operation costs.

Simple anterior orbitotomy.

OBJECTIVE: Simple anterior orbitotomy is one of the popular surgical procedures through the orbital cavity. In this approach no bony orbitotomy is required so very satisfactory cosmetic results should be achieved. The authors of this paper report on three patients with space-occupying lesions in orbital cavity which were operated by anterior orbitotomy techniques without craniotomies. METHODS: Three patients with space-occupying lesions in the orbital cavity underwent a microsurgical procedure with simple anterior orbitotomy. RESULTS: No bony orbitotomy was used in this technique and the cosmetic results were very satisfactory. Although the surgical area is very narrow, no neurological deficit has appeared after this procedure using microsurgical operative procedures. CONCLUSION: Although the orbital cavity is very narrow, multiple neurological important structures occur in this area. Traction of the ocular bulb and optic nerve can be harmful for the patient. Therefore, many the surgeons prefer the transfrontal intracranial approach with superior orbital craniotomy for wide exposure. One of these three cases is a typical example for the simple anterior orbitotomy which is a useful operative approach for patients with solid space-occupying lesions in the superior part of the orbital cavity. Another patient with a hydatid cyst in orbital cavity was operated successfully via a simple anterior orbitotomy. The third patients was 6 years old and shows that the procedure can be used easily in children as well.

Electrorhinomanometric evaluation of nasal functions in transseptal-transsphenoidal hypophysectomy.

OBJECTIVE: The prospective study in 23 patients, who were undergone transseptal-transsphenoidal hypophysectomy, underlines the rhinologic aspects of this technique. MATERIALS AND METHODS: Preoperative and postoperative subjective complaints were compared, postoperative nasal respiratory functions were evaluated by means of electrohinomanometry. RESULTS: Nasal respiratory functions were preserved postoperatively in the patients with normal preoperative nasal anatomy (no statistical difference); while, in patients with obstructive deviation of the nasal septum, an improvement in nasal respiratory functions were noted as a result of simultaneously performed septoplasty (p < 0.01). CONCLUSION: Our results emphasize the importance of the collaboration of otorhinolaryngology and neurosurgery teams for the sake of postoperative nasal functions.

Nasomaxillary osteotomy in lesions of the central compartment of the middle cranial base.

The pituitary fossa, sphenoid rostrum, sphenoid sinus, nasopharynx, pterygopalatine fossa and clivus are the components of the central compartment of the middle cranial base. It is a surgical challenge to gain access to this region. This fact has led to the development of a number of surgical procedures reported in the literature. However, none of these techniques can provide a wide and direct exposure to the middle cranial fossa without morbidity on its own. In this report, nasomaxillary osteotomy is described as a satisfactory alternative to reach the middle cranial fossa. With the nasomaxillary osteotomy technique, a wide access can be obtained to the central compartment of the skull base, caudally till the inferior clivus and upper cervical vertebrae (C1, C2). Since bilateral, internal carotid arteries are in sight laterally, the technique provides a secure resection of tumors with marked lateral extensions. Repositioning the translocated bone segment, surrounding the apertura piriformis, results in satisfactory cosmesis postoperatively. The technique is discussed on the basis of eight cases with the histopathological diagnosis of squamous cell carcinoma (1 case), olfactory neuroblastoma (2 cases), chordoma (2 cases) and juvenile nasopharyngeal angiofibroma (3 cases). No vascular complication has been encountered. One chordoma patient died of the disease in the follow-up period. All other cases, including one squamous cell carcinoma patient, are alive and disease-free without cosmetic deformity. In conclusion, nasomaxillary osteotomy provides a wide and direct exposure to the central compartment of the skull base in a relatively short period of time, securing the vascular and neural structures. Besides, it offers the advantage that it can be combined with other techniques in extensive tumors, while cosmesis and nasal functions are preserved.

Hypertonic saline in hydatid disease.

The objective of this study was to determine the scolicidal effects of saline in different concentrations using different exposure times and to examine whether hypertonic saline can be used to irrigate the abdomen when there is a free intraperitoneal perforation of hydatid disease. Various concentrations of saline solutions (0.09%, 3.0%, 6.5%, 10%, 15%, 20%, 25%, 30%) were added to concentrated echinococcus granulosus sediments for the following times: 1, 2, 3, 4, 5, 10, 15, 30, 45, and 60 minutes. Normal (0.09%), 3.0%, and 6.5% saline resulted in high viability ratios after 60 minutes' exposure. Complete lethality for 10%, 15%, 20%, 25%, and 30% saline occurred at the end of 75, 10, 6, 3, and 3 minutes, respectively. During the second part of the study, 20 Sprague-Dawley rats were used for abdominal saline irrigation in four groups: 30% NaCl for 3 minutes; 20% NaCl for 6 minutes; intravenous isotonic dextrose water and furosemide plus 30% NaCl irrigation for 3 minutes; the same prophylactic therapy plus 20% NaCl irrigation for 6 minutes. Sodium and chloride values rose significantly (20-30%) shortly after hypertonic saline irrigation in each group (p < 0.01). Support with isotonic dextrose and furosemide before irrigation did not have any beneficial effect on biochemical values or mortality. The 24- and 48-hour mortality rates were 70% and 90%, respectively. These studies illustrate that the scolicidal effect of hypertonic saline is limited in low concentrations, but an increase in the concentration can augment its adverse effects. Peritoneal irrigation with hypertonic saline should be avoided for intraabdominal perforated hydatid disease. Therefore, we concluded that hypertonic saline is not a good scolicidal agent to prevent recurrence of hydatid disease.

Petrosal presigmoid approach to the petro-clival and anterior cerebellopontine region (extended retrolabyrinthine, transtentorial approach).

Intradural tumours affecting the clivus may be divided into three categories depending the area primarily involved by tumour. The second area extends from the spheno-occipital synchondrosis to the level of the jugular foramina. This area is best approached through the petrosal approach and suited for patients with serviceable hearing on the side of the lesion. 35 cases having skull base lesions were operated by the Skull Base Surgery Group of Ege University Medical Faculty between October 1993 and December 1997. 8 out of 35 cases having the intradural tumours affecting the petroclival and anterior cerebellopontine region, the petrosal presigmoid approach was performed in 4 patients. As hearing was absent in another 4 patients, the translabyrinthine route was coupled a the petrosal craniotomy (transtemporal approach). The aim of this article is to highlight the definitions, indications, hints and pitfalls of the approach from the otoneurological point of view.

Spinal hydatid disease.

Vertebral hydatid cysts are rare and found in less than 1% of all the cases of hydatidosis. Neural compression is common in vertebral hydatidosis. The prognosis is generally regarded as very poor. This paper examines the natural history and complications which may arise during the treatment of vertebral hydatid cyst, and discusses their treatment. Thirteen cases of hydatid disease affecting the vertebrae are presented. The patients were admitted with symptoms of spinal cord compression. Twelve were treated by laminectomy and one by costotransversectomy. Low back pain radiating to the legs and lower extremity weakness were the predominant symptoms. Different degrees of pareses were present in 12 patients. Nine patients had impaired sensation in lower extremities. In 13 patients, 27 operations were performed. The major complication of surgery was the death of one patient due to the formaline irrigation. The surgical goal should be an extensive removal of the cysts and affected bone. The surgical area needs to be irrigated with hypertonic saline. Mebendazole or albendazole therapy seems to retard the recurrences and control the disease.

Protective effect of vitamin A on acute radiation injury in the small intestine.

The objective of this study was to examine the influence of vitamin A on the development of early radiation-induced reactions in the rat small intestine. The early effects of intraoperative gamma-radiation on the small bowel utilizing the terminal ileum of Sprague-Dawley rats and the protective effect of supplemental vitamin A on acute radiation injury were investigated. Three groups were included in the study: group I (10 rats) was the surgical control group; group II (13 rats) underwent only intraoperative irradiation; and group III (10 rats) was the vitamin A plus irradiation group. Exteriorized terminal ileal segments of groups II and III were exposed to a single fraction of 20 Gy of intraoperative gamma-irradiation. On the seventh postoperative day, terminal ileal segments of all rats were resected and histopathologically evaluated for ulceration, enteritis cystica profunda, atypical epithelial regeneration, fibrosis, vascular sclerosis, and inflammatory process. Although none of the above findings were present in the surgical control group, group III rats experienced less severe effects than group II rats. The results suggest the early side effects of radiation may be prevented by vitamin A supplementation.

Surgery of intramedullary spinal cord tumors.

The diagnosis and management of intramedullary spinal cord tumors have been significantly influenced by new diagnostic and surgical tools such as MRI, ultrasonic aspiration, intraoperative ultrasound, and evoked potential monitoring. In this study we compared the surgical results of our earlier cases using conventional methods with more recent cases using these new methods. We report our experience based on 44 adult cases. Histologic diagnosis revealed ependymoma (20 cases), astrocytoma (15 cases), glioblastoma multiforme (1 case), and other histologic diagnoses (8 cases). We performed 20 gross total resections, 19 partial resections, and 5 biopsies. The mean follow-up period was 25.8 months (3 months-10 years). Surgical results were improvement in 11 patients (25%), stabilization in 24 (54%), and deterioration in 9 (20%). The first 28 cases (group A) were diagnosed using conventional myelography and CT myelography. The more recent 16 cases (group B) were diagnosed with MRI and operated on using techniques such as ultrasonic aspiration, intraoperative monitoring and ultrasound imaging. Radical surgery (total excision) was performed in 36% (n = 10) of group A, while it was possible in 62% (n = 10) of group B. Deterioration after operation was noted in 28% (n = 8) of group A, but only 6.2% (n = 1) of group B. These results stress the importance of a preoperative MRI scan and the positive effects of intraoperative ultrasound imaging, ultrasonic aspiration, and evoked potential monitoring on surgical results. With the help of these tools, most intramedullary spinal cord tumors may be diagnosed and treated surgically with significantly decreased risk. Radical surgery was possible in as many as 62% of our more recent patients. Partial resection with radiotherapy should be confined to patients with high-grade astrocytomas.

Recurrence of meningiomas versus proliferating cell nuclear antigen (PCNA) positivity and AgNOR counting.

Meningiomas have a wide range of biological potential and clinical behaviour. Histological findings are helpful in recognizing the malignant potential but often fail to correlate with clinical behaviour. This study attempts to correlate the silver nucleolar organizer regions (AgNORs) and proliferating cell nuclear antigen (PCNA) with clinicopathological features of biological activity. Thirty-four completely resected meningiomas were classified as benign [19], atypical [6] and malignant [9]. Forty-eight initial and recurrent tumour materials were investigated for staining of AgNORs and immunohistochemistry using monoclonal antibodies against PCNA (clone 19A2 and PC10). There were no difference between the recurrent and non-recurrent cases with regards to AgNOR, PC10 and 19A2 values. Also, no significant difference was found between the primary and recurrent tumours. Both PC10 and 19A2 labelling indices (LI) showed a significant difference between benign and malignant meningiomas. The 19A2 LI was 0.56 +/- 0.21 in benign and 2.45 +/- 16 in atypical meningiomas. The 19 A2 counts showed significant difference between benign and atypical tumours but PC10 values failed to show such a correlation AgNOR and PCNA indices were not found to be useful in predicting recurrences compared to the surgical procedure and histopathological criteria.

Fibrolamellar hepatocellular carcinoma "it is not a ordinary case for Mediterranean countries".

The fibrolamellar variant of hepatocellular carcinoma (HCC) is an uncommon tumour with distinctive clinical and histological features. Although the first case of fibrolamellar hepatocellular carcinoma (FI-HCC) was described by Edmondson in 1956, and later confirmed in five patients by Peters, the majority of reports followed those of Berman et al. and Craig et al. A case of FI-HCC, which is rarely diagnosed in Mediterranean countries including Turkey, is presented in the following report.

Intracerebral hematoma after evacuation of chronic subdural hematoma.

A case of intracerebral hemorrhage occurring after evacuation of a chronic subdural hematoma is presented. The mechanism of this complication is not clear. However, hemorrhage into previously undetected areas of contusion, damage to cerebral vasculature secondary to rapid perioperative parenchymal shift, and sudden increase in cerebral blood flow with focal disruption of autoregulation have been postulated as causes. Although this is a rare complication after decompressive operation for chronic subdural hematoma, it should be suspected and investigated without delay in patients who deteriorate postoperatively.