A modified method in laparoscopic peritoneal catheter implantation: the combination of preperitoneal tunneling and pelvic fixation.

Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13-44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.

Duodenal somatostatinoma: a case report and review of the literature.

INTRODUCTION: About 70% of well-differentiated endocrine tumors arise from the gastrointestinal tract. Duodenal well-differentiated endocrine tumors account for only 2.6% of all neuroendocrine tumors. Following the first two case reports of somatostatin-secreting tumors in 1977, fewer than 200 cases of somatostatinoma have been reported. These tumors of the duodenum are usually silent and asymptomatic, but can cause gastrointestinal symptoms. Depending on the localization of the tumor, multiple surgical procedures can be performed, ranging from local resection to pancreaticoduodenectomy. CASE PRESENTATION: Here, we report a case of a submucosal duodenal mass in a 42-year-old Turkish White man presenting with nausea, vomiting, fatigue and abdominal pain. The treatment decision of pancreaticoduodenectomy made preoperatively was later altered to intraoperative removal via local resection with sphincteroplasty. CONCLUSION: Tumors of the periampullary region are considered highly malignant, and the Whipple operation is usually the only procedural treatment. In the current case, we decided not to perform pancreaticoduodenectomy but to excise the mass intraoperatively, and consequently avoided unnecessary resection of the pancreas and anastomosis to undilated hepatic and pancreatic ducts. This protective strategy prevented duodenum- and pancreas-related morbidity.

Unchanged serum adipokine concentrations in the setting of short-term thyroidectomy-induced hypothyroidism.

OBJECTIVE: To investigate short-term effects of thyroidectomy-induced hypothyroidism on leptin, adiponectin, and resistin concentrations in association with anthropometric data. METHODS: Thirty premenopausal women with euthyroid nodular goiter-mean age, 44.0 ± 11.6 years; mean body mass index (BMI), 28.6 ± 5.9 kg/m2; 13 obese, 7 overweight, and 10 normal weight subjects-scheduled for total thyroidectomy were included in the study. Serum leptin, adiponectin, resistin, free triiodothyronine, free thyroxine, thyroid-stimulating hormone, glucose, insulin, and C-reactive protein concentrations, lipid profile, and anthropometric variables were determined in the euthyroid state (preoperatively) and the hypothyroid state (postoperatively, with a thyroid-stimulating hormone concentration >30 mIU/L). RESULTS: Body weight, BMI, waist and hip circumferences, body fat mass, and serum lipid concentrations increased significantly after thyroidectomy. No significant difference was found between preoperative and postoperative serum leptin, adiponectin, and resistin concentrations. Fat tissue mass-corrected leptin, adiponectin, and resistin concentrations did not differ significantly between euthyroid and hypothyroid periods. Thyroid hormone concentrations showed no significant correlations with adipokine levels. CONCLUSION: Serum adipokine concentrations seem not to change significantly during short-term thyroidectomy-induced hypothyroidism despite significant increases in body weight, BMI, fat mass, and lipid concentrations.

Do we adequately diagnose early gastric cancer in Turkey.

BACKGROUND/AIMS: Late diagnosis of patients with advanced gastric cancer is due to late admission of patients or overlooked early gastric cancers in early endoscopies. We retrospectively evaluated gastroscopic results in our clinic over 9 years and assessed outcomes of all patients diagnosed and treated for gastric cancers, including early gastric cancers. MATERIALS AND METHODS: We retrospectively evaluated all gastroscopic reports in our hospital between January 2000 and January 2009, dividing these patients into two time periods: 2000-2004 and 2005-2009. For all patients with early gastric cancers, we assessed age, gender, macroscopic tumor type, location in the stomach, type of surgery, histopathological verification of the tumor, lymph node involvement and general patient condition. RESULTS: Of the 37,768 patients who underwent gastroscopy, 3.53% (536 patients) during 2000-2004 and 4.3% (973 patients) during 2005-2009 were diagnosed with gastric cancer. During these two time periods, 21 (3.91%) and 61 (6.26%), respectively, of the patients who underwent radical surgical intervention were diagnosed with histopathologically proven early gastric cancers. CONCLUSION: The rate of early gastric cancers among patients with gastric cancer was lower in Turkey than in western countries and Japan. As in other western countries, screening endoscopy is not feasible in Turkey. The use of chromoendoscopy and magnified endoscopy, particularly in patients with alarm symptoms and in risk groups, may increase the rate of early diagnosis.

Choice of the optimal pancreaticojejunal anastomosis technique: how can we improve patient safety in pancreatic surgery?

BACKGROUND/PURPOSE: The cause of the morbidity and mortality following pancreaticoduodenectomy (PD) in the surgical treatment of benign and malignant diseases of the periampullary region is leakage from the pancreaticojejunal anastomosis. The size of the main pancreatic duct and the texture of the remnant pancreas are very important factors for a secure pancreaticojejunal anastomosis. METHODS: A new technique was developed for patients having pancreatic ducts smaller than 3 mm and a hard remnant pancreas. RESULTS: Pylorus-preserving PD was performed for 28 patients who underwent PD at our hospital between January 2004 and January 2007, without mortality. The new technique was used in the 8 patients who had pancreatic ducts smaller than 3 mm and a hard remnant pancreas. With our new technique, different from other previously described techniques, the anastomosis was performed with the sutures passing from the cut-surface of the parenchyma of the pancreas. All patients were operated on by the same surgeon and surgical team. None of the patients developed a fistula. CONCLUSIONS: We believe that this anastomosis technique can be performed securely in patients having a hard remnant pancreas and a main pancreatic duct smaller than 3 mm.

H pylori: Treatment for the patient only or the whole family?

AIM: To compare the effects of treatment of H pylori-infected individuals with the effects of treatment of individuals as well as all H pylori-infected family members. METHODS: H pylori-positive patients with similar demographic specifications were prospectively randomized with respect to treatment, with a triple regimen of either patients and all H pylori-positive family members living togetherI (group I) or patients only (group II). Nine months after treatment, all patients were assessed for H pylori positivity. RESULTS: There were 70 H pylori-positive patients in each group; patients in groups I and II lived with 175 and 190 H pylori-positive relatives, respectively. Age, sex and H pylori positivity rate were similar in both groups of relatives. Nine months after 14 d standard triple therapy, H pylori positivity was 7.1% in group I patients and 38.6% in group II patients [P < 0.01, OR = 8.61 95% confidence interval (CI): 2.91-22.84]. CONCLUSION: The present results indicate bad environmental hygienic conditions and close intra-familial relationships are important in H pylori contamination. These findings indicate all family members of H pylori-positive individuals should be assessed for H pylori positivity, particularly in developing countries where H pylori prevalence is high; they also suggest patients, their spouses and all H pylori-positive family members of H pylori-positive individuals should be treated for H pylori infection.

Endolaparoscopic approach in the management of gastroesophageal reflux disease: an experimental study in pigs.

INTRODUCTION: Chronic reflux of gastric content to the esophagus causes retrosternal burning, pain, and regurgitation, and results in histopathologic changes that may culminate in adenocarcinoma. Insufficiency of the lower esophageal sphincter and hiatal hernia are the two principal causative factors. In this paper, we present the early results of a new antireflux operation in pigs. MATERIALS AND METHODS: The status of physiologic reflux was determined in 5 pigs (approximately 40-45 kg) with 24-hour pH monitorization. Under endoscopic guidance, a trocar was inserted into the stomach (similar to the percutaneous endoscopic gastrostomy technique). The endoscope was put into the retroflexed position; a mucomuscular pursestring suture was placed around the endoscope at the cardia and tied. Ten days later, pH monitorization was repeated to evaluate the effectiveness of the method. Late postoperative results have been reevaluated by 24-hour pH monitorization in the sixth month. RESULTS: The procedure achieved statistically significant improvements in total reflux time, number of reflux periods, number of long reflux periods, the longest reflux period, and the DeMeester score. The preoperative and postoperative DeMeester scores of the individual animals were 179.24-0.94, 11.48-0.98, 68.4-3.74, 132.2-46.49, and 38.72-5.86, respectively. Even though there appeared to be a slight increase in the pH monitorization levels after 6 months, these results did not reach significant degrees, and compared to the physiological reflux, the results were remarkable. CONCLUSIONS: The results obtained showed considerable decreases in physiologic reflux in all animals. We believe that this endoluminal, laparoendoscopic operation can be used in the treatment of gastroesophageal reflux disease as a minimally invasive method.

Endoscopic diagnoses and CLO test results in 9239 cases, prevalence of Helicobacter pylori in Istanbul, Turkey.

BACKGROUND: Helicobacter pylori is implicated in the etiology of gastric and duodenal ulcer, non-ulcer dispepsia, atrophic gastritis, gastric adenocarcinoma and lymphoma. METHODS: Between November 1995 and December 2004, the presence of H. pylori was investigated using the CLO test in 9239 patients who underwent upper gastrointestinal endoscopy at a single institution in Istanbul, Turkey. The results were evaluated as early-late positive, and negative. RESULTS: There were 4667 women (50.51%) with a mean age of 44.5 years (range, 13-90 years), and 4572 men (49.49%) with a mean age of 45.7 years (range, 11-85 years). The CLO test was positive in 41.44% of cases. The most frequent symptoms on admission were epigastric pain (46.2%) and burning (19.6%). The most frequent endoscopic diagnosis was pangastritis (64%) and non-erosive duodenitis (30.5%). The H. pylori positivity was 61.53% during the first 5-year period and 38.47% during the second 5-year period. The H. pylori positivity was significant in patients using non-steroidal anti-inflamatory drugs and tobacco (P < 0.001). DISCUSSION AND CONCLUSION: Helicbacter pylori prevelance remains an important health problem for Turkey although it has diminished in parallel to the national development during the last years. Helicbacter pylori, as a first-degree carcinogen, should be investigated and eradicated particularly in high-risk patients.

Endometriotic umbilical port site metastasis after laparoscopy.

We present the case of a 40-year-old woman who had been previously operated for endometrioma 2 years ago by laparoscopy, with the complaint of an umbilical mass with cyclical pain pattern. The dark-colored mass was excised and pathology report revealed it to be an endometriotic implant.

Can bile duct injuries be prevented? "A new technique in laparoscopic cholecystectomy".

BACKGROUND: Over the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis. However, the incidence of bile duct injury in laparoscopic cholecystectomy is still two times greater compared to classic open surgery. The development of bile duct injury may result in biliary cirrhosis and increase in mortality rates. The mostly blamed causitive factor is the misidentification of the anatomy, especially by a surgeon who is at the beginning of his learning curve. Biliary tree injuries may be decreased by direct coloration of the cystic duct, ductus choledochus and even the gall bladder. METHODS: gall bladder fundus was punctured by Veress needle and all the bile was aspirated. The same amount of fifty percent methylene blue diluted by saline solution was injected into the gall bladder for coloration of biliary tree. The dissection of Calot triangle was much more safely performed after obtention of coloration of the gall bladder, cystic duct and choledocus. RESULTS: Between October 2003 and December 2004, overall 46 patients (of which 9 males) with a mean age of 47 (between 24 and 74) underwent laparoscopic cholecystectomy with methylene blue injection technique. The diagnosis of chronic cholecystitis (the thickness of the gall bladder wall was normal) confirmed by pre-operative abdominal ultrasonography in all patients. The diameters of the stones were greater than 1 centimeter in 32 patients and calcula of various sizes being smaller than 1 cm. were documented in 13 cases. One patient was operated for gall bladder polyp (our first case). Successful coloration of the gall bladder, cystic duct and ductus choledochus was possible in 43 patients, whereas only the gall bladder and proximal cystic duct were visualised in 3 cases. In these cases, ductus choledochus visibility was not possible. None of the patients developed bile duct injury. CONCLUSION: The number of bile duct injuries related to anatomic misidentification can be decreased and even vanished by using intraoperative methylene blue injection technique into the gall bladder fundus intraoperatively.