Predicting coexisting thyroid cancer with primary hyperparathyroidism in an endemic region of multinodular goiter: evaluating the effectiveness of preoperative inflammatory markers.

Purpose: The aim is to examine the efficacy of inflammatory indicators to predict thyroid cancer in patients with primary hyperparathyroidism (PHPT) in an endemic region of nodular goiter. Methods: The prospective database was reviewed to identify patients operated on with the diagnosis of PHPT and thyroid disease between April 2015 and June 2021. Permanent pathologic reports were used as the gold standard for diagnosis. Detailed imaging data with peripheral blood inflammation indices were analyzed to assess their predictive values for concomitant PHPT with thyroid cancer. Postoperative complications and the duration of hospitalization were also reviewed. Results: Thyroid malignancy accompanying PHPT was found in 13 patients (26.0%) out of 50 who had concurrent surgery. The analysis regarding inflammatory indexes revealed nothing significant between thyroid cancer and preoperative blood biochemistry (P > 0.05). In the concurrent surgery group, recurrent laryngeal nerve injury was observed in 1 patient (2.0%) and the mean hospital stay was longer. Conclusion: In endemic regions of nodular thyroid disease, thyroid cancer might accompany PHPT. The value of inflammatory indexes to predict thyroid malignancy in PHPT is controversial and should not be employed in the surgical decision-making process.

Gardner's syndrome: Simultaneous diagnosis and treatment in monozygotic twins.

Gardner's syndrome (GS) is a very rare autosomal dominant multisystem disease. Osteomas, skin and soft tissue tumors are present with gastrointestinal polyposis. The polyps have very high malignancy potentials. If prophylactic resection is not performed, colorectal cancer development is inevitable in all patients with GS. Polyposis is usually asymptomatic. Therefore, careful evaluation of extraintestinal findings of the disease is very important for early diagnosis. In this article, diagnosis and treatment of GS are presented in monozygotic twins, which have not been previously described in the literature. The diagnostic process, which started with dental complaints of one case, was carried out in an effective manner and then, prophylactic surgery was performed in twins. This article aimed to make clinicians and dentists attentive for early diagnosis of disease and to review treatment options.

Evaluation of FRP Confinement Models for Substandard Rectangular RC Columns Based on Full-Scale Reversed Cyclic Lateral Loading Tests in Strong and Weak Directions.

Although many theoretical and experimental studies are available on external confinement of columns using fiber-reinforced polymer (FRP) jackets, as well as numerous models proposed for the axial stress-axial strain relation of concrete confined with FRP jackets, they have not been validated with a sufficient amount and variety of experimental data obtained through full-scale tests of reinforced concrete (RC) columns with different geometrical and mechanical characteristics. Particularly, no systematical experimental data have been presented on full-scale rectangular substandard RC columns subjected to reversed cyclic lateral loads along either their strong or weak axes. In this study, firstly, test results of five full-scale rectangular substandard RC columns with a cross-sectional aspect ratio of two (300 mm × 600 mm) are briefly summarized. The columns were tested under constant axial load and reversed cyclic lateral loads along their strong or weak axes before and after retrofitting with external FRP jackets. In the second stage, inelastic lateral force-displacement relationships of the columns are obtained analytically, making use of the plastic hinge assumption and different FRP confinement models available in the literature. Finally, the analytical findings are compared with the test results for both strong and weak directions of the columns. Comparisons showed that use of different models for the stress-strain relationship of FRP-confined concrete can yield significantly non-conservative or too conservative retrofit designs, particularly in terms of deformation capacity.

Chronic pelvic abscedation after completion proctectomy in a rectal stump insufficiency; treatment with gracilis muscle flap following vacuum assisted closure therapy.

Presacral abscess formation due to rectal stump insufficiency following Hartmann procedure is very rare complication. If the abscess cavity is large, it might delay the reversal of the stoma and will probably result in a devastating future functioning of the neorectum. Moreover, very invasive treatments will be required in order to prevent severe septic complications. We present the case of a 58-year-old man with a past history of Hartmann procedure for a low rectal carcinoma who presented with rectal stump insufficiency and a large presacral abscess. Following extensive debridement and rectal stump resection, a vacuum-assisted closure (VAC) system was applied to the large abscess cavity to facilitate gracilis muscle flap reconstruction and to optimize wound healing. The satisfactory results showed in the present report led us to favor a combination of VAC therapy and a gracilis muscle flap in intrapelvic and perineal reconstruction in the case of large defects associated with high risks of septic complications.

Effects of ozone oxidative preconditioning on liver regeneration after partial hepatectomy in rats.

AIM: Similar protective effect of ischemic and ozone oxidative preconditioning (OzoneOP) in hepatic ischemia-reperfusion (I/R) injury was demonstrated, providing evidences that both preconditioning settings shared similar biochemical mechanisms of protection. We investigated the effects of OzoneOP on liver regeneration after 70% partial hepatectomy (PHx) in rats. METHODS: Rats were divided into three groups: PHx, I/R + PHx, and OzoneOP + I/R + PHx groups. Ozone (intraperitoneal, 1.2 mg/kg) was given to rats subjected to I/R and 70% hepatectomy daily five times before operation. At 24 hr and 48 hr after resection, samples were collected for the measurement of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), tumor necrosis factor alpha (TNF-α), and interleukin-6 (IL-6). Moreover, liver regeneration rate, proliferating cell nuclear antigen (PCNA) labeling index, mitotic index, and histopathological examination were evaluated. RESULTS: OzoneOP reduced liver injury determined by liver histology and serum transaminases. There was a rise in serum TNF-α and IL-6 levels in the I/R + PHx group whereas OzoneOP significantly decreased the rise in the level of TNF-α but not IL-6 on the 24 hr and 48 hr of reperfusion. Moreover, liver regeneration in OzoneOP + PHx group, as assessed by the regenerated liver weight, mitotic, and PCNA-labeling index, was significantly improved when compared to I/R + PHx group. CONCLUSION: These results suggest that OzoneOP ameliorates the hepatic injury associated with I/R and has a stimulatory effect on liver cell regeneration that may make it valuable as a hepatoprotective modality.

Effects of ozone oxidative preconditioning on radiation-induced organ damage in rats.

Because radiation-induced cellular damage is attributed primarily to harmful effects of free radicals, molecules with direct free radical scavenging properties are particularly promising as radioprotectors. It has been demonstrated that controlled ozone administration may promote an adaptation to oxidative stress, preventing the damage induced by reactive oxygen species. Thus, we hypothesized that ozone would ameliorate oxidative damage caused by total body irradiation (TBI) with a single dose of 6 Gy in rat liver and ileum tissues. Rats were randomly divided into groups as follows: control group; saline-treated and irradiated (IR) groups; and ozone oxidative preconditioning (OOP) and IR groups. Animals were exposed to TBI after a 5-day intraperitoneal pretreatment with either saline or ozone (1 mg/kg/day). They were decapitated at either 6 h or 72 h after TBI. Plasma, liver and ileum samples were obtained. Serum AST, ALT and TNF-α levels were elevated in the IR groups compared with the control group and were decreased after treatment with OOP. TBI resulted in a significant increase in the levels of MDA in the liver and ileal tissues and a decrease of SOD activities. The results demonstrated that the levels of MDA liver and ileal tissues in irradiated rats that were pretreated with ozone were significantly decreased, while SOD activities were significantly increased. OOP reversed all histopathological alterations induced by irradiation. In conclusion, data obtained from this study indicated that ozone could increase the endogenous antioxidant defense mechanism in rats and there by protect the animals from radiation-induced organ toxicity.

Diagnostic adequacy of surgeon-performed ultrasound-guided fine needle aspiration biopsy of thyroid nodules.

BACKGROUND: Surgeon-performed ultrasonography (US) of thyroid nodules might serve as a potential therapeutic guide to designate accurate surgical or clinical intervention. OBJECTIVE: To evaluate the diagnostic adequacy of surgeon-performed ultrasonography guided fine needle aspiration biopsy (FNAB) of thyroid nodules, the factors responsible for diagnostic adequacy and the impact of surgeon-performed US on treatment approach. METHODS: Retrospective review of a single surgeon performed 621 US-guided FNABs without on-site cytological specimen assessment. Outside US findings were compared to the surgeon-performed US. Measured variables and outcomes for the study included diagnostic adequacy rates and the effects of detected differences between US reports on treatment variability. RESULTS: Diagnostic adequacy rate of surgeon-performed US-guided FNAB was determined to be 94.52% without on-site specimen evaluation by cytologist. Non-diagnostic specimens occurred in 34 of 621 (5.48%) nodules. The differences detected between the outside US and surgeon-performed US altered invasive treatment algorithm in 30 (5.47%) patients. FNAB was avoided for 15 (2.7%) patients. Total thyroidectomy became the preferred surgical option in 15 (2.7%) patients after the discovery of additional nodules in the contralateral lobe. CONCLUSION: Surgeon-performed US offers clear clinical benefits in terms of diagnostic yield of FNAB with providing valuable additional data that might alter surgical treatment approach.

Our long-term results of Tenckhoff peritoneal dialysis catheters placement via laparoscopic preperitoneal tunneling technique.

Previously we described the technique to lessen complications of continuous ambulatory peritoneal dialysis (CAPD) and to achieve immediate use of the catheter. In this study we evaluated our long-term results of the technique. A total of 61 procedures were carried out in 58 patients from September 2003 to February 2009. All patients were followed in our hospital CAPD clinic. Demographic, medical, operative, postoperative, and other information regarding complications and continued patient management was obtained retrospectively from the patients' medical records and entered into a computerized database. There were 33 men and 25 women. The mean age was 58 years. In 29 of the 58 patients indication of catheter placement was end stage renal failure combined with diabetes mellitus. Mean follow-up time was 33.31 ± 20.11 months. Catheter related complications were outflow obstruction (n=3, 5.2%) and peritonitis (n=2, 3.4%). Etiologies of catheter removal were out flow obstruction (n=2), recovery from renal disease (n=2), peritonitis (n=1), and pregnancy (n=1). The mean catheter survival time was found 5.57 ± 0.17 years. Our long-term results showed that the method ensured accurate placement, preperitoneal fixation, and immediate use of the catheter for routine peritoneal dialysis. Preperitoneal fixation of the catheter decreased outflow obstruction over long-term follow-up.

Effect of erythropoietin on liver regeneration in an experimental model of partial hepatectomy.

BACKGROUND AND AIM: The liver shows remarkable regeneration ability after damage or resection. The main stimulant for hepatic regeneration is resection. Erythropoietin (EPO), which was initially used for anemia therapy, is today known as a general tissue protector owing to its anti-inflammatory, anti-oxidant, anti-apoptotic, and angiogenic properties. This study aims to investigate the effect of systemically administered EPO on liver regeneration after partial hepatectomy. METHODS: Forty-eight male Wistar albino rats were randomly split in two groups A and B consisting of 24 rats each. Standard 70% hepatectomy was performed on the rats in group A. The same surgical procedure was performed on the rats in group B, and they were additionally administered 3000 U/kg/subcutaneous EPO. The rats were sacrificed 24, 48, and 72 h after resection. The groups were compared in terms of biochemical, morphological, and histopathological parameters. RESULTS: The biochemical results showed that the administration of EPO decreased aspartate aminotransferase levels significantly (p < 0.05) at 24 h after hepatectomy. A comparison of the groups in terms of relative liver weight showed that EPO-treated groups exhibited a statistically significant increase (p < 0.05) for all three time periods. Histopathology results showed that in the EPO-treated groups, the mitosis index at 48 and 72 h, double nuclei cell number at 72 h, and proliferating cell nuclear antigen ratio at 48 h showed a significant increase (p < 0.05). CONCLUSION: Our study showed that systemically administering high-dose EPO increases regeneration by affecting the biochemical, morphological, and histopathological parameters after liver resection.

The presence of oxidized low-density lipoprotein and inducible nitric oxide synthase expression in renal damage after intestinal ischemia reperfusion.

Intestinal ischemia/reperfusion (I/R) is a complex phenomenon that causes destruction of both local and remote tissues. The objective of this study was to investigate the possible participation of oxidized low-density lipoproteins (oxLDLs) and inducible nitric oxide synthase (iNOS) expression in renal tissue damage after intestinal I/R. The superior mesenteric artery was blocked for 30 minutes, followed by 24 hours of reperfusion. At the end of the reperfusion period, renal tissues were removed; the presence of oxLDL, superoxide dismutase enzyme activity, malondialdehyde levels, and iNOS expression were evaluated. I/R resulted in positive oxLDL staining in renal tissue. Compared with control rats, tissue from the I/R group showed significantly higher malondialdehyde levels and lower superoxide dismutase enzyme activity. Strong and diffuse iNOS expression was present in the I/R group. Our findings support the hypothesis that I/R of intestinal tissue results in oxidative and nitrosative stress and enhances lipid peroxidation in the end organ. These data show that oxLDL accumulates in rat renal tissue after intestinal I/R. Antioxidant strategies may provide organ protection in patients with reperfusion injury, at least by affecting interactions with free radicals, nitric oxide, and oxLDL. This study demonstrates for the first time that oxLDL may play a role in renal tissue damage after intestinal I/R. Antioxidant strategies may be beneficial for protection from reperfusion injury.

Postoperative complications after abdominal surgery in patients with chronic obstructive pulmonary disease.

BACKGROUND/AIMS: Chronic obstructive pulmonary disease is a well-known independent risk factor for the development of postoperative pulmonary and cardiac complications after thoracic or nonthoracic surgery. We aimed to determine the risk factors and complications of abdominal surgery in chronic obstructive pulmonary disease patients. MATERIAL AND METHODS: Thirty-two patients diagnosed with chronic obstructive pulmonary disease out of 89 patients who underwent abdominal surgery at Zonguldak Karaelmas University Medical School Hospital enrolled in the study. RESULTS: Pulmonary and cardiac complication ratios were found high in chronic obstructive pulmonary disease patients. Postoperative pulmonary and cardiac complications were documented in 21.8% and 28.1% of chronic obstructive pulmonary disease patients respectively. There were no differences in terms of complications, according to the severity of the disease in chronic obstructive pulmonary disease patients. While smoking and age did not effect the postoperative complications in chronic obstructive pulmonary disease patients, bronchodilator use increased postoperative cardiac risks. We found that laparoscopic surgery reduced the risk for postoperative pulmonary complications compared with open surgical procedures. No differences were found in terms of complication regarding to the type of incision and the duration of surgery. CONCLUSION: The patients with chronic obstructive pulmonary disease had high ratio of the pulmonary and cardiac complications. The complication rate was higher for surgical sites closer to the diaphragm such as the upper abdomen. Laparoscopy will reduce the risk for postoperative pulmonary complications compared with open surgical procedures. Based on our preliminary data and considering the lack of controlled trials, bronchodilators should be used with great caution particularly in the individuals with chronic obstructive pulmonary disease and cardiac comorbidity.

Does intraabdominal use of Ankaferd Blood Stopper cause increased intraperitoneal adhesions?

BACKGROUND: The aim of this study was to investigate whether intraabdominal Ankaferd Blood Stopper (ABS) causes increased intraabdominal adhesion formation and to determine any side effects of ABS in vivo. METHODS: The present experimental study was designed to examine the effects of Ankaferd solution on peritoneal adhesion formation in a rat model of cecal abrasion. Intraperitoneal adhesions were assessed macroscopically and histopathologically on the 10th postoperative day. The possible adverse affects of ABS on liver and lung tissues were analyzed histopathologically, and blood chemistry was also evaluated. RESULTS: Our study revealed that ABS reduced intraperitoneal adhesion formation in an experimental rat model. The blood chemistry was not disturbed due to ABS administration. Intraperitoneal administration of ABS led to some minor changes in the lungs and serosal surfaces of the intestines, with minor architectural changes in the liver that were not considered as toxic. Further studies with various application doses and routes with more detailed cellular analysis are thus warranted to clarify the possible pleiotropic and adverse effects of this new agent away from hemostasis. CONCLUSION: There was less intraperitoneal adhesion formation in the ABS group than in the control group and saline group. Intraperitoneal administration of ABS has no toxic effects on blood chemistry or the lungs, kidneys and the liver, but it has some minor adverse effects.

Mitigation of indomethacin-induced gastric mucosal lesions by a potent specific type V phosphodiesterase inhibitor.

AIM: To investigate the gastroprotective effect of vardenafil against indomethacin-induced gastric damage. METHODS: Forty-eight female Wistar albino rats were randomly divided into 6 groups. Group 1 received saline only. Group 2 (indomethacin) received indomethacin. Rats in group 3 and 4 were pretreated with different doses of famotidine. Group 5 and 6 were pretreated with different doses of vardenafil. Rats in groups 3 to 6 received 25 mg/kg indomethacin 30 min after pretreatment. The animals were sacrificed 6 h later and their stomachs were opened. Gastric lesions were counted and measured. The stomach of each animal was divided in two parts for histopathological examinations and nitric oxide (NO) and malondialdehyde (MDA) assays, respectively. RESULTS: There were no gastric mucosal lesion in the saline group but all rats in the indomethacin group had gastric mucosal ulcerations (ulcer count; 6.25 +/- 3.49, and mean ulcer area; 21.00 +/- 12.35). Ulcer counts were diminished with famotidine 5 mg/kg (4.12 +/- 2.47, P > 0.05), 20 mg/kg (2.37 +/- 4.43, P < 0.05), vardenafil 2 mg/kg (4.37 +/- 3.06), and vardenafil 10 mg/kg (1.25 +/- 1.38, P < 0.05) compared to the indomethacin group. Gastric mucosal lesion areas were diminished with famotidine 5 mg/kg (8.62 +/- 2.97, P < 0.001) , famotidine 20 mg/kg (0.94 +/- 2.06, P < 0.001), vardenafil 2 mg/kg (6.62 +/- 5.87, P < 0.001), and vardenafil 10 mg/kg (0.75 +/- 0.88, P < 0.001) compared to the indomethacin group. MDA levels were significantly higher in indomethacin group (28.48 +/- 14.51), compared to the famotidine 5 mg/kg (6,21 +/- 1.88, P < 0.05), famotidine 20 mg/kg (5.88 +/- 1.60. P < 0.05), vardenafil 2 mg/kg (15.87 +/- 3.93, P < 0.05), and vardenafil 10 mg/kg (10.97 +/- 4.50, P < 0.05). NO concentration in gastric tissues of the famotidine groups were significantly increased (P < 0.05), but the NO increases in the vardenafil groups were not statistically significant. Histopathology revealed diminished gastric damage for pretreatment groups compared to the indomethacin group (P < 0.05). CONCLUSION: Vardenafil affords a significant dose-dependent protection against indomethacin induced gastric mucosal lesions in rats.

Low-density lipoproteins oxidized after intestinal ischemia/reperfusion in rats.

BACKGROUND: Intestinal ischemia/reperfusion (I/R) is a complex phenomenon causing destruction of both local and remote tissues, as well as multiple-organ failure. We investigated the role of lipid peroxidation in damage to intestinal, liver, and lung tissues in this pathology. MATERIALS AND METHODS: The superior mesenteric artery was blocked for 30 min followed by 24 h of reperfusion. Tissues were removed and the presence of oxidized LDL, the activities of the superoxide dismutase enzyme, malondialdehyde levels, and inducible nitric oxide synthase expression were each evaluated in the intestinal, liver, and lung tissues. RESULTS: While there was no staining in the control group tissues, ischemia/reperfusion resulted in positive oxidized LDL staining in all of the I/R test group tissue samples. Inducible nitric oxide synthase expression was significantly increased in the ischemia/reperfusion group tissues. Compared with those of the control group rats, the ischemia/reperfusion group tissues showed significantly higher malondialdehyde levels and lower superoxide dismutase activities. CONCLUSIONS: This study demonstrated for the first time that oxidized LDL accumulated in the terminal ileum, liver, and lung tissues after intestinal ischemia/reperfusion. This occurrence (or the presence of oxidized LDL) may be an indicator of ongoing oxidative stress and enhanced lipid peroxidation. Augmentation of inducible nitric oxide synthase expression may play a role in progression of inflammation and LDL oxidation. These data support the hypothesis that cellular oxidative stress is a critical step in reperfusion-mediated injury in both the intestine and end organs, and that antioxidant strategies may provide organ protection in patients with reperfusion injury, at least through affecting interaction with free radicals, nitric oxide, and oxidized LDL.

Effect of 2-octyl-cyanoacrylate on ischemic anastomosis of the left colon.

INTRODUCTION: 2-octyl-cyanoacrylate may be a good alternative in ischemic colon anastomosis without impairment of tissue perfusion. METHODS: Forty male Wistar albino rats were randomized into four experimental groups (n = 10 in each group). In group 1 (control), a well-perfused left colonic segment was transected, and free ends were anastomosed by propylene sutures. In groups 2, 3, and 4, the animals underwent a standardized surgical procedure to induce ischemic left colon anastomosis. In group 2, an end-to-end anastomosis was created using six interrupted 6-0 polypropylene sutures between ischemic edges. In group 3, after approximating the mesenteric and antimesenteric edges of the anastomosis with two 6-0 polypropylene sutures, 2-octyl-cyanoacrylate was applied between the edges. In group 4, anastomosis was created by the same technique as described in group 2, and additionally 2-octyl-cyanoacrylate was applied on suture line. Rats were killed on day 4 following operation. Anastomotic integrity, intraperitoneal adhesion scores, anastomotic bursting pressures, and tissue hydroxyproline levels were recorded. Histopathological examination of the anastomosis was also performed. RESULTS: There were no statistically significant differences among groups with respect to anastomotic integrity (p =.142). The mean bursting pressure values were 81.1 +/- 23.83, 43.3 +/- 26.06, 15.8 +/- 11.3, and 17.6 +/- 18.02 in groups 1, 2, 3, and 4, respectively. There were no statistically significant differences among groups 2, 3, and 4 with respect to tissue hydroxyproline levels and bursting pressure levels. The highest adhesion scores were observed in groups 3 and 4. DISCUSSION: 2-octyl cyanoacrylate does not have additional advantages in the healing of experimental ischemic colon anastomosis.

Evaluation of a new hemostatic agent Ankaferd Blood Stopper in experimental liver laceration.

INTRODUCTION: Hemorrhage is a leading cause of death after trauma. It is also the major cause of operating room deaths among patients who undergo liver surgery. Various techniques and materials have been attempted to manage bleeding, but a standard method has not been defined yet. We studied the hemostatic effects of Ankaferd Blood Stopper on liver injury in comparison with regenerated oxidized cellulose. MATERIALS AND METHODS: Thirty Wistar albino rats underwent partial hepatic laceration by scissors. The animals were randomized to the treatment of resected surface with either Ankaferd Blood Stopper (ABS, n = 11) or regenerated oxidized cellulose (Surgicel, n = 9), or were left untreated (controls, n = 10). All the animals were resuscitated with lactated Ringer's solution at 3.3 ml/min/kg to a mean arterial pressure (MAP) of 100 mmHg. Survival time, total blood loss, resuscitation volume, and MAP were recorded for 30 min or until death. The rats that were alive at the end of 30 min were sacrificed with blood withdrawal from catheters. RESULTS: Rats in the ABS and Surgicel groups survived significantly longer than rats in the control group (p =.0001). There were no significant differences between the ABS and the Surgicel groups in survival (p =.91). Application of ABS and Surgicel was associated with a significant reduction in blood loss compared to controls (p =.008), with no significant differences between active treatment groups (p =.74). The resuscitation volume was not different. CONCLUSIONS: ABS is as effective as Surgicel in achieving hemostasis following partial liver excision in an experimental rat model.

Erythropoietin: a possible cytoprotective cytokine in acute necrotizing pancreatitis.

BACKGROUND/PURPOSE: Despite decades of research and clinical trials, a specific therapeutic treatment for acute pancreatitis (AP) has yet to be developed. The aim of the present study was to investigate the effects of erythropoietin on the severity of taurocolic acid-induced acute necrotizing pancreatitis. METHODS: Forty-seven male Wistar albino rats were randomized into seven experimental groups. In group I, animals were sham-operated (n = 5). In groups II, III, IV, IIepo, IIIepo, and IVepo, AP was induced by sodium taurodeoxycholate treatment (n = 7). In groups II, III, and IV, 1 ml normal saline and in groups IIepo, IIIepo, and IVepo, 1000 U/kg body weight erythropoietin (EPO) was administered intramuscularly immediately after the induction of AP. Animals were killed at 24, 48, and 72 h postoperatively. Histopathological and biochemical evaluations were performed. RESULTS: The serum levels of interleukin-6 (IL-6) and tissue levels of malondialdehyde were found to be significantly lower in EPO-administered groups when compared with the levels in groups without EPO treatment. The severity of pancreatic edema, acinar necrosis, inflammation, and perivascular infiltrate were reduced in all the EPO groups compared with the no-treatment groups. CONCLUSIONS: Our findings may reflect the possible cytoprotective effect of EPO in acute necrotizing pancreatitis.