Effects of postoperative parenteral nutrition with different lipid emulsions in patients undergoing major abdominal surgery.

PURPOSE: This study was designed to investigate the effects of total parenteral nutrition (PN) using different lipid emulsions in patients undergoing major abdominal surgery. METHODS: Fifty-two patients were randomized to receive soybean oil + medium chain triglycerides (MCT) (group I), soybean oil + olive oil (group II), soybean oil + olive oil + fish oil (group III) as a lipid source. PN was started on postoperative day 1 and patients were maintained on PN for a minimum period of 4 days. Laboratory variables (CRP, prealbumin, transferrin) were measured before surgery and on postoperative days. RESULTS: Three treatment groups were included in the study. Patients in group I received long chain triglycerides (LCT) + LCT/MCT emulsion (%75 LCT + %25 LCT/MCT); Patients in group II received olive oil based emulsion (80% olive oil + 20% soybean oil, ClinOleic); Patients in group III received fish oil in addition to olive oil based emulsion (%85 ClinOleic + %15 Omegaven; Fresenius Kabi). The following 14 parameters were assessed: body weight, CRP, prealbumin, transferrin, tumor necrosis factor-α, interleukin-6, total antioxidant status, thiobarbituric acid reactive substances, oxidized low density lipoprotein-2, complete blood cell, international normalized ratio, D-dimer, activated partially thromboplastin time, prothrombin time. All other parameters showed no differences among the groups. CONCLUSION: The results of our trial demonstrate a potential beneficial effect of soybean oil/olive oil based lipid emulsions for use in PN regarding inflammatory response and oxidant capacity in the treatment of patients.

Gastric metastasis of ectopic breast cancer mimicking axillary metastasis of primary gastric cancer.

Ectopic breast tissue has the ability to undergo all the pathological changes of the normal breast, including breast cancer. Gastrointestinal metastasis of breast cancer is rarely observed and it is very difficult to differentiate gastric metastases from primary gastric cancer. We present a case of 52-year-old female, who suffered from abdominal pain. Physical examination showed a palpable mass in the left anterior axilla and computerized tomography revealed gastric wall thickening with linitis plastica. When gastroscopic biopsy showed no signs of malignancy, excisional biopsy was performed in the left axilla. Histological examination revealed invasive lobular carcinoma of the breast, consistent with ectopic breast cancer. Further gastroscopic submucosal biopsies and immunohistochemical studies revealed gastric metastases of invasive lobular carcinoma. Axillary ectopic breast tissue carcinomas can mimic axillary lymphadenopathies. Additionally, gastric metastasis of breast cancer is an uncommon but possible condition. To the best of our knowledge, this is the first report of ectopic breast cancer with gastric metastasis.

Tuberculosis of the breast in a patient undergoing hemodialysis.

A 61-year-old female patient with diabetes undergoing maintenance hemodialysis presented with fever and swelling of her right breast. She had been unresponsive to nonspecific antimicrobial therapies. Breast tuberculosis and tuberculous lymphadenitis were diagnosed by excision biopsy and tissue culture. A combination antituberculous treatment including isoniazid, rifampin, ethambutol, and pyrazinamide was started and resulted in the remission of the lesions by the end of the first month of therapy.

Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity.

PURPOSE: Dysfunction of pelvic floor may cause many different symptoms, such as urinary and anal incontinence, obstructed defecation and constipation. No previous studies have examined all of these symptoms together. The purposes of the present study were to determine prevalence of pelvic floor disorders among the female population and to evaluate the impact of age, parity, and mode of delivery on these disorders. METHODS: The study was performed on a general population of Turkish women. Women were excluded who were pregnant, who were within 6 months postpartum, who had cognitive disorders or neurological diseases, and who had a history of previous gastrointestinal, anorectal, or gynecological surgery. A questionnaire about urinary incontinence, anal incontinence, constipation, and obstructed defecation along with an extensive obstetric history was administered to 4002 women in face-to-face interviews. All symptoms were defined according to the standard terminology. RESULTS: The median age of the participants was 41 years (range, 15-86). Of the women interviewed, 1067 had no deliveries, 434 women delivered by cesarean only, and 2501 women had one or more vaginal deliveries. Five hundred thirty women had delivered one child, 1880 women had delivered 2 to 3 children, and 582 women had delivered ≥4 children. Overall, 67.5% of women experienced pelvic floor dysfunction of at least one major type. The prevalence of each pelvic floor disorder evaluated in this study was as follows: anal incontinence, 19.8%; urinary incontinence, 50.7%; constipation, 33.2%; and obstructed defecation, 26.8%. Analysis of risk factors demonstrated that age was the major factor associated with the development of pelvic floor dysfunction. Vaginal delivery and higher parity increased the risk of both urinary and defecatory symptoms of pelvic floor dysfunction. CONCLUSION: The study data demonstrate that pelvic floor dysfunction is a common problem among women and it is strongly linked to childbirth and aging.

Colon perforation caused by migration of a bone graft following a posterior lumbosacral interbody fusion operation: case report.

STUDY DESIGN: This is a case report. OBJECTIVE: The purpose was to report a patient whose migrated L4-S1 femur graft led to perforation of the cecum. SUMMARY OF BACKGROUND DATA: Autograft bone use during spinal surgery is quite commonplace nowadays. With time due to infection, technical mishaps, or disease recurrence, these autografts may break off their points of attachments and with their subsequent migration lead to serious complications. METHODS: The patient who had the history of a stabilization operation performed for his L5-S1 spondylolisthesis grade III by way of a L4-L5, S1 transpedicular rod screw presented with high fever and abdominal tenderness. The patient underwent a laparatomy and a perforation on the medial aspect of the cecum, and a femur graft extending into the cecum through the perforation was found. RESULTS: The graft was removed and the cecum was primarily repaired. The patient was discharged on the 15th postoperative day after an uneventful postoperative course. CONCLUSION: We have presented a case whose migrated L4-S1 femur graft led to perforation of the cecum. We recommend that frequent radiologic follow-up should be done in patients at risk to show complications early enough to avert severe consequences.

Applicability of the Gail model for breast cancer risk assessment in Turkish female population and evaluation of breastfeeding as a risk factor.

The Gail model is considered the best available means for estimating risk of breast cancer development, but it has not yet been applied systematically and validated in Turkish female population. This study was designed to evaluate the performance of the Gail model for Turkish female population. Additionally duration of breastfeeding was examined as a possible risk factor. Our analysis included 650 patients with invasive breast carcinoma (group 1) and 640 women with negative results who had undergone a screening mammography on visiting a mammary care unit (group 2). Two groups were compared with regard to individual risk factors included in the Gail model and also duration of breastfeeding. The Gail model was used to predict 5-year risk for each woman. Age and first live birth > or =30 years were associated with an increased relative risk for breast cancer development. Age at menarche, previous breast biopsy, atypical hyperplasia, and number of first degree relatives with breast cancer were found to be non-significant. The Gail model showed 13.3% sensitivity and 92% specificity in estimating the risk of breast cancer development in Turkish women. Positive predictive value was 63%, negative predictive value was 51.9%, and validity index was 53.1%. Duration of breastfeeding was significantly longer in group 1 than 2 (median 17 vs. 13 months). The proportion of parous women with no breastfed was higher in group 1 than 2. The currently used Gail model does not seem to be an appropriate breast cancer risk assessment tool for Turkish female population.

Unroofing and curettage for the treatment of acute and chronic pilonidal disease.

BACKGROUND: Various surgical techniques are available in the management of pilonidal sinus, but controversy concerning the optimal surgical approach persists. The present study analyzes the outcome of unroofing and curettage as the primary intervention for acute and chronic pilonidal disease. METHODS: A total of 297 consecutive patients presenting with chronic disease, acute abscess, or recurrent disease were treated with unroofing and curettage. The wound was left open to heal by secondary intention. Hospitalization, time required to resume daily activities and return to work, healing time, and recurrence rates were recorded. RESULTS: All patients were discharged within the first 24 h after operation. The median period before returning to work was 3.2 +/- 1.2 days, and the mean time for wound healing was 5.4 +/- 1.1 weeks. Six patients were readmitted with recurrence of the disease within the first six postoperative months. All recurrences were in patients who did not follow the wound care advice and who did not come to regular weekly appointments. Patients with recurrence underwent repeat surgery by the same technique with good results. CONCLUSIONS: Unroofing and curettage for pilonidal sinus disease is an easy and effective technique. The vast majority of the patients, including those with abscess as well as those with chronic disease, will heal with this simple procedure, after which even recurrences can be managed successfully with the same procedure. Relying on these results, we advocate unroofing and curettage as the procedure of choice in the management of pilonidal disease.

Intussusception in adult and pediatric patients: two different entities.

PURPOSE: Intussusception is one of the most common abdominal emergencies in pediatrics, but adult intussusception is an uncommon entity and most surgeons have only limited experience in treating this disease. The purpose of this study was to highlight the differences between pediatric and adult intussusception. METHODS: The records of 40 patients during 14 years were reviewed retrospectively. The symptoms, diagnosis, sites of intussusception, associated pathologies, and treatment methods of each patient were analyzed. RESULTS: A total of 31 pediatric and 9 adult patients were included in the study. In the pediatric group, bloody stool and vomiting were the most common symptoms whereas adult patients commonly presented with abdominal pain. The physical examination was diagnostic in a remarkable proportion of the pediatric patients but the diagnosis was suggested based on imaging techniques in the adults, and preoperative diagnosis was more successful in the pediatric group. Intussusception was more often associated with an underlying pathology in adults and no adult patient underwent nonoperative reduction, whereas pediatric patients were managed either with hydrostatic reduction or surgery. CONCLUSIONS: Although intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective.

Suprarenal symplastic leiomyoma of the inferior vena cava.

We report on a case of a leiomyoma in the inferior vena cava that appeared in the image to be located in the adrenal gland. En bloc excision of the tumor with the right adrenal gland and the involved segment of the vena cava was carried out. Histopathological work-up of the tumor revealed smooth muscle fibers and marked nuclear pleomorphism consistent with symplastic leiomyoma. This case report presents a distinct histological variant of the rarely seen primary smooth muscle tumor of the inferior vena cava.

Mesh erosion as a complication of laparoscopic fundoplication with prosthetic hiatal closure: report of a case.

BACKGROUND: Laparoscopic fundoplication has become the standard procedure for surgical management of gastroesophageal reflux disease. Simple cruroplasty is associated with a high recurrence rate and most authors recommend the use of prosthetic meshes for crural closure. METHODS: Herein we report a patient who was admitted with the complaint of severe dysphagia a year after laparoscopic fundoplication with prosthetic hiatal closure. RESULTS: The patient presented with mesh erosion into the esophagus and required a distal esophageal resection. CONCLUSIONS: This case demonstrates that appropriate surgical technique is important for preventing mesh-related complications. A small-sized mesh should be placed so as to have no contact with the esophagus and should be secured sufficiently to the diaphragmatic crura to avoid the potential complications of mesh reinforcement.

Trocar site hernia after laparoscopic cholecystectomy.

AIM: The aim of this study was to elucidate the influence of pre and perioperative factors on the development of trocar site hernia after a laparoscopic cholecystectomy procedure. PATIENTS AND METHODS: A total of 776 patients who underwent a laparoscopic cholecystectomy procedure in our Department of General Surgery between 1999 and 2004 were assigned as the study group. The control group included patients without trocar site hernias after a cholecystectomy. The effect of five variables, including gender, age, body mass index (BMI), operation duration, and the type of cholecystitis on the development of a trocar site hernia after a laparoscopic cholecystectomy was assessed by univariable and multivariable models. RESULTS: In the univariate analysis, female gender (P = 0.021), older age (P < 0.001), higher BMI at the time of surgery (P < 0.001), and an increased duration of surgery (P < 0.001) have been found to increase the likelihood of a trocar site hernia formation. However, in the multivariable model, the gender was not a significant variable to influence the development of this complication. CONCLUSIONS: The development of a postoperative trocar site hernia may be prevented by the closure of 10-mm trocar sites in patients who are older than 60 years, obese, and who have a longer duration of operation.

Laparoscopic fundoplication with prosthetic hiatal closure.

BACKGROUND: Despite the good results reported after laparoscopic fundoplication, failure is still a major problem. Hiatal disruption is one of the common patterns of anatomical failure. The aim of this study was to compare the results of suture repair of diaphragmatic crura with routine polypropylene mesh reinforcement in addition to suture repair. METHODS: A total of 551 patients who underwent laparoscopic fundoplication for gastroesophageal reflux disease between March 1998 and July 2004 were included into the study. Crural closure had been performed with simple primary suture repair alone between March 1998 and July 2002 (n = 335, group I), and mesh reinforcement of the hiatal repair was performed routinely thereafter (n = 176, group II). These groups were evaluated prospectively. RESULTS: We observed a significantly lower rate of recurrence in group II than in group I. After a 2-year follow-up, the rate of anatomic morphologic recurrence was 6.0% in group I and 1.8% in group II. Considering the recurrence rate, there was significant statistical difference. The overall recurrence rate in our series was 4.6%. There was no correlation between the size of the hernia and recurrence. No significant difference was found between groups regarding the rate of postoperative dysphagia. We have not observed any complications related to the use of polypropylene mesh in group II. CONCLUSION: The results of this study suggest that polypropylene mesh reinforcement increases the success rate for laparoscopic hiatal hernia repair without causing an additional complication burden. We propose routine use of mesh reinforcement in laparascopic antireflux surgery.

Effects of basic fibroblast growth factor and phenytoin on healing of abdominal wall fascia and colonic anastomoses.

The aim of this study was to investigate the effects of basic fibroblast growth factor (bFGF) and phenytoin on wound healing in rats compromised by methylprednisone. This study was conducted in four groups consisting of 20 male Wistar rats. Rats in groups 2, 3, and 4 had a daily injection of methylprednisolone 5 mg/kg/day for 15 days. Laparotomy and sigmoid transsection were performed on day 15. In the postoperative period, rats in group 1 received no medication, group 2 received methylprednisolone 5 mg/kg/day intramuscularly, group 3 received bFGF 5 microg/kg on days 1-3 subcutaneously, and group 4 received phenytoin 40 mg/kg/day intraperitoneally. bFGF and phenytoin had a positive effect on tensile strength, hydroxyproline content, and wound healing parameters in abdominal wall fascia. In colonic anastomosis, phenytoin corrected all parameters, but bFGF had no effect.

Effects of probiotics on radiation-induced intestinal injury in rats.

OBJECTIVE: Radiotherapy is an important aspect of multimodal cancer therapy, but radiation-induced acute intestinal injury is a common and serious problem. Disruption of morphologic mucosal integrity and normal bacterial microflora after abdominal radiation leads to malabsorption and bacterial translocation. METHODS: Lactobacillus bulgaricus strain isolated from yogurt was given as a probiotic to rats subjected to radiotherapy. On postradiation day 8 rats were killed. Mesenteric lymph nodes, liver, and spleen were excised for microbiologic examinations. Segments of jejunum, ileum, and colon were evaluated for the presence of inflammation, vascularity, and mucus cells. RESULTS: The results of this study suggest that probiotics may have a protective effect on intestinal mucosa. CONCLUSION: Probiotics added as substrates can be given by an oral or enteral route to patients who undergo radiotherapy to prevent radiation-induced enteritis and related malnutrition.

The effect of polypropylene mesh on ilioinguinal nerve in open mesh repair of groin hernia.

OBJECTIVES: Repair of groin hernia is one of the most common operations performed by general surgeons, and mesh repair methods have gained wide acceptance. Chronic pain is the most serious long-term complication that can occur after repair of groin hernia. The development of chronic pain after herniorraphy has been attributed to several mechanisms, including damage to sensory nerves and mesh inguinodynia. MATERIAL AND METHODS: Twenty-four rabbits underwent bilateral inguinal dissection and synthetic polypropylene mesh laid on one side. Bilateral inguinal dissection was performed again after 3 months, and samples of nerve tissue were taken from both sides for histological examination. RESULTS: Light microscopic examination of the sections of control group peripheral nerves were in normal appearance, but the nerve fascicles in experimental group operated with mesh showed axonal dilation and mild-to-severe loss of myelinated axons. Examination of semi-thin and ultra-thin sections in control group peripheral nerve fascicles showed normal morphology. Ultrastructural nerve morphology in experimental group operated with mesh exhibited endoneurinal edema with thickening of both endoneurium and perineurium, causing separation of nerve fibers. Myelin sheaths of fibers showed an ondulation toward the axoplasm and the endoneurium. Separation of myelin layers from each other as a prominent feature of myelin degeneration in nerve fibers was also observed. Axoplasms exhibited edema and crystallization. CONCLUSIONS: The light microscopic and ultrastructural changes seen in peripheral nerves in experimental group operated with mesh suggested that mechanical compression of peripheral nerves is associated with myelin degeneration, endoneurinal and perineurial edema, fibrosis, axonal loss, and edema that may cause peripheral neuropathy. Chronic groin pain after hernia repair can be possibly caused by the entrapment of peripheral nerves in the scar tissue formed by the mesh.