Evaluation of the protective effect of quercetin against cisplatin-induced renal and testis tissue damage and sperm parameters in rats.

The protective effect of quercetin on cisplatin-induced renal and testicular tissue damage was investigated using biochemical, histopathological and histological approaches. A total of 40 male rats were divided into 5 groups as follows: control; cisplatin alone; quercetin alone; cisplatin + quercetin; and quercetin + cisplatin. Cisplatin was administered to rats at a single dose of 7 mg kg(-1) intraperitoneal. Quercetin was administered by gavage daily for 10 days at dosage 50 mg kg(-1) . At the end of the study serum, total antioxidant capacity (TAC) levels and total oxidant status (TOS) were determined. Malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT) and xanthine oxidase (XO) were studied separately in serum, renal tissue and testicular tissue. Renal and testicular morphological alterations were assessed, histopathologically. Epididymal sperm concentration, motility and morphology were investigated. Testicular and renal TAC and TOS values did not alter significantly. Renal CAT levels were increased by cisplatin and cisplatin plus quercetin groups that is reversed by administration of quercetin before cisplatin. MDA, CAT, SOD ve XO levels of testicular tissue did not differ significantly. Cisplatin and cisplatin plus quercetin groups had decreased sperm motility ratio and increased abnormal spermatozoa. Quercetin partially reverses some of the cisplatin-related pathological effects on kidney and testis.

Lymphovascular invasion, as a prognostic marker in patients with invasive breast cancer.

PURPOSE: The markers of prognosis are used to predict the clinical course of disease and the outcome for patients with invasive breast cancer. Our aim is to investigate the relationship of peritumoural lymphovascular invasion (LVI) with well-known prognostic markers. PATIENTS AND METHODS: Eighty-one surgically treated patients with invasive breast cancer were evaluated in this study during a mean follow-up period of 46 months (12-72). The patient's age (menopausal status), tumour size, nuclear grade, axillary lymph node involvement, and hormone receptor status were determined as markers of the prognosis. The relationship of LVI with these markers was established. RESULTS: Except for menopausal status (p = 0.25) a close relationship was found between the presence of LVI and studied prognostic factors. LVI was positive in 29% of T1, 54% of T2 (p = 0.028) and 100% of T3 tumours (p = 0.002). The rate of LVI (+) has increased gradually as 0%, 38% and 77% (p = 0.001) with grades 1, 2 and 3 respectively. Positive LVI has been determined in 85% (p < 0.0001) and 73% (p = 0.0004) of oestrogen and progesterone receptor negative tumours respectively. LVI was present in 14% and 73% (p < 0.0001) of patients with negative and positive axilla respectively. Metastatic cancer caused mortality in seven patients of whom 86% had more than four involved axillary nodes, and 100% LVI (+). CONCLUSION: The high rate of positive LVI shows a close relationship with known markers of poor prognosis. The presence of LVI can predict a worse outcome for patients with invasive breast cancer. LVI may be used as an indicator of aggressive behaviour, metastatic ability (nodal and systemic) of the primary malignancy.

Does the approach to the groin make a difference in hernia repair?

BACKGROUND: Laparoscopic and open preperitoneal hernia repair techniques both use the preperitoneal space. This study investigated whether the surgical approach to the inguinal canal affects outcome measures. METHODS: One hundred sixty patients with inguinal hernia were assigned randomly into open anterior (42), open preperitoneal (39), laparoscopic transabdominal preperitoneal (39), and laparoscopic total extraperitoneal (40) groups according to the surgical method. The peroperative serum tumor necrosis factor-alpha (TNF-alpha) levels, interleukin-6 (IL-6) levels, VAS scores at 6 and 48 h, per- and postoperative complications, and recurrence rates were determined as main variables. RESULTS: The serum IL-6 levels were 335 +/- 1.8, 283 +/- 1.8, 283 +/- 1.4, and 269.3 +/- 1.6 pg/ml in the open anterior, posterior, transabdominal preperitoneal, and total extraperitoneal groups, respectively (P < 0.01). The TNF-alpha levels were highest in the open anterior group. The pain scores were lower in groups undergoing the posterior approach than in the open anterior approach group. CONCLUSION: The approach to the inguinal canal through the preperitoneal space appears to be less invasive than the transinguinal anterior approach.

Surgery is the procedure of choice for the treatment of patients with toxic adenoma in an endemic goitre area.

PURPOSE: Toxic adenoma is one of the main causes of hyperthyroidism. We investigated the efficacy of surgery in the treatment of toxic adenoma. METHODS: Serum thyroid stimulating hormone (TSH) measurement, ultrasound and scintigraphy of the thyroid were made for diagnostic purpose. The safety of surgery was evaluated by postoperative clinical course of patients. The efficacy of surgery was determined by the function of the remaining thyroid tissue. RESULTS: The incidence of hyperthyroidism was 53% in surgically treated patients with nodular goitre in our iodine deficient region. The cause of thyrotoxicosis was toxic adenoma in 15 patients (14%). Suppressed serum TSH levels indicated the hyperthyroidism in all of 15 patients. Solitary solid adenoma was found by ultrasonographic examination, and solitary autonomous hot nodule by thyroid scintigraphy. Surgical treatment consisted of unilateral total lobectomy. It was the primary treatment in 13 patients. Two patients had surgery as secondary treatment after unsuccessful primary radioactive iodine application. The early postoperative clinical course of all patients was uneventful. Thirteen patients who had surgery as primary treatment had normal thyroid function postoperatively contrary to other two patients who became hypothyroid after having unsuccessful radioiodine therapy, and surgery as the secondary treatment. CONCLUSIONS: The incidence of hyperthyroidism and toxic adenoma is high in our surgically treated patients with nodular goitre. The diagnosis of toxic adenoma is not difficult by serum TSH measurements, and ultrasound and nuclear imaging of the thyroid. Surgery is effective and safe, and the treatment of choice for patients with toxic adenoma in order to control radically the hyperthyroidism and to achieve the goal of providing the euthyroid status.

Gallbladder carcinoma associated with gallstones.

The great majority of gallbladder carcinoma is associated with gallstones. This cancer is generally diagnosed in advanced stages, and the prognosis is very poor. In this study we analysed retrospectively 3119 patients with cholelithiasis alone, and 35 patients with gallbladder cancer. Thirty-three of 35 cancer cases (94%) were associated with gallstones. Cancer rate was 1% in patients with cholelithiasis. Mean age was significantly higher in patients with gallbladder cancer than in those with cholelithiasis alone, 66.5 and 53.3 respectively (p < 0.0001). Sixty four percent of cancer cases were between 61-70 years of age, and the rate of carcinoma was 2.8% in this group (p < 0.001). The cancer rate was found to be 0.29% inpatients under 60 years of age, and 2.56% in those over 60 years (p < 0.001). According to Nevin's classification, 88% of cancer cases were found in advanced stages. Seventeen (52%) cases were diagnosed preoperatively. Ninety four percent of patients with preoperative diagnosis were in advanced stages compared with 31% of patients with incidental diagnosis (p = 0.0002). Patients with early stages carcinoma were alive and free of disease 58 months after operation. Average survival was only 9.5 months in patients with advanced cancer. We conclude that the incidence of gallbladder carcinoma increases significantly in patients over 60 years of age. Today preoperative early diagnosis is almost impossible, and long-term survival is possible only for early cases incidentally discovered at postoperative pathological examination of removed gallbladders for gallstone disease. Radical surgery has not provided long-term survival. We recommend close follow-up of patients with cholelithiasis, and enlargement of indication for cholecystectomy in a selective manner, considering some criteria in patients older than 55 years of age who are known with long-standing cholelithiasis.

Effects of neurotensin on the healing of experimental anastomosis of the colon.

The leakage of colonic anastomoses increases perioperative morbidity significantly. The purpose of the study was to investigate the influence of neurotensin, an intestinal trophic peptide, on the healing of colonic anastomosis. Forty-two Wistar-albino rats were separated into three equal groups: Group 1 (control group)--segmental resection of the left colon and end-to-end anastomosis; Group 2 (dexamethasone group)--resection and anastomosis, plus 0.1 mg/kg/day of dexamethasone; Group 3 (neurotensin group)--same surgical procedure plus 300 micrograms/kg/day of neurotensin. Bursting pressure and tissue hydroxyproline content were determined as parameters of the anastomosis strength and healing on the 3rd and 7th days postoperatively. On the 3rd day, mean bursting pressures were 141.4, 146.7 and 73.1 (p = 0.0001) cm of water in the control group, dexamethasone and neurotensin groups respectively. On the 7th day, bursting pressures were measured as 237.4, 100.6 (p = 0.0001) and 72.7 (p = 10(-6)) cm of water, in the control group, dexamethasone and neurotensin groups respectively. Between the 3rd and 7th days, bursting pressures were increased significantly in the control group (p = 0.0001), decreased in the dexamethasone (p = 0.048), and maintained their lowest values in the neurotensin (p = 0.96) groups. On the 7th day, mean hydroxyproline levels were measured as 9.20, 3.30 (p = 0.007), 2.86 (p = 0.007) micrograms, in the control group, dexamethasone, and neurotensin groups respectively. Between the 3rd and 7th days, tissue hydroxyproline levels were increased significantly in the control group (p = 0.004), decreased in the dexamethasone (p = 0.03), and maintained their lowest values in the neurotensin (p = 0.87) groups. The anastomosis resistance to intraluminal pressure was weak, tissue collagen content was insufficient, and healing was inadequate in the dexamethasone and neurotensin groups in respect to the control group. We concluded that neurotensin impaired the healing, and affected the strength of the colonic anastomosis.

Gallstone ileus: demographic and clinical criteria supporting preoperative diagnosis.

Gallstone ileus is an uncommon intestinal obstruction with unexpectedly high mortality. It is not easy to diagnose this uncommon disease preoperatively. The aim of our study is to establish some simple criteria supporting the suspicion of gallstone ileus in patients with small intestine obstruction. We retrospectively analysed hospital records of 8 patients with gallstone ileus and 1230 cases of mechanical intestinal obstruction, excluding incarcerated external hernias. Gallstones were the cause of occlusion in 0.9% (8/886) of patients with small bowel obstruction. All our 8 patients were women with an average age of 74 years. Gallstone ileus was diagnosed in 18% of elderly (+70 years) women with small intestine obstruction. This rate raised to 36% in this group of elderly women if previous abdominal operations that would produce adhesion were excluded. Previous ultrasonographic examinations had demonstrated gallstones in 5 (62%) patients. Only one patient (12.5%) was diagnosed preoperatively with plain X ray film demonstrating gas in the biliary tract. The obstruction was treated with enterolithotomy. Cholecystectomy was performed in two (25%) patients. The mortality was 25% in early postoperative period. Advanced age, female sex, and positive patient's history of known gallstone in the gallbladder have appeared as strong criteria. Gallstone ileus is a common cause of intestinal obstruction in elderly women with no previous abdominal operations and without incarcerated external hernia. Pneumobilia is more common radiological finding to establish the diagnosis of gallstone ileus in these patients.

Perfusion and functional anatomy of the splenic remnant supplied by short gastric vessels.

BACKGROUND: Surgeons have described many methods to preserve the injured spleen for the maintenance of host defence. The volume and the perfusion of remaining splenic tissue are important for better functional results. Imaging the functioning tissue with radionuclide provides information about the physiology of the concerning organ. METHODS: Thirty rats were separated into three groups: control, explorative laparotomy alone; partial splenectomy, upper part of the spleen supplied by short gastric vessels was preserved after partial resection; and devascularized spleen, the entire spleen was preserved after ligation of splenic artery. The size, functional anatomy, and perfusion status of splenic tissue were assessed by liver-spleen scintigraphy using radiolabeled heat denatured red blood cells. RESULTS: In the partial splenectomy group, splenic radioactivity count, spleen/liver ratio, and radionuclide uptake were mildly reduced, and found to be 87% (P = 0.012), 91% (P = 0.16), and 88% (P <0.001) of the normal spleen, respectively. The area of functional tissue in the upper splenic remnant was 51% (P <0.001) of the normal spleen. In the devascularized spleen group, the radioactivity count, the ratio, and the uptake were 38% (P <10(-6)), 36% (P <10(-6)), and 49% (P <10(-6)) of the normal spleen respectively. The area of functional tissue in the devascularized spleen was calculated as 47% (P <10(-6)) of the normal spleen. CONCLUSIONS: The collateral circulation is insufficient for proper function of the entire spleen after disconnection of the main arterial blood supply. The functional tissue is markedly impaired. On the other hand, the upper part of the spleen is remained well perfused via the short gastric vessels. The collateral circulation is satisfactory for this splenic tissue after reduction of its volume. That size splenic tissue seems to have satisfactory functional ability. Proper functional results mostly depend on the balance between the volume and blood supply of the remaining splenic tissue.

Immune function of the upper splenic remnant supplied by short gastric vessels.

OBJECTIVE: To study the immune function of the upper third of the spleen supplied by short gastric vessels after two thirds partial splenectomy. DESIGN: Experimental study. SETTING: Teaching hospital, Turkey. MATERIAL: Sixty Wistar-albino rats, 20 in each group. INTERVENTIONS: Control = sham laparotomy; partial splenectomy = the upper third of the spleen supplied by short gastric vessels was preserved after two thirds partial splenectomy and dividing the main vascular supply; and total splenectomy. At the end of the sixth week postoperatively, antigenic stimulation was induced with an injection of pneumococcal suspension in 10 animals from each group. 0.5 ml of diluted Indian ink was injected into the aorta. MAIN OUTCOME MEASURES: Histological architecture of splenic tissue, and changes in the white pulp after antigenic stimulus. Bacteriological analysis with aerobic blood culture. Phagocytic activity as counted by Indian-ink-laden macrophages. The ability to produce antibodies as measured by serum IgM concentrations. RESULTS: Histological architecture of splenic tissue was normal. Germinal centres (p = 0.02), lymphoid follicles (p = 0.09), and their ratio (p = 0.0006) in the white pulp of the splenic remnant was significantly increased after antigenic stimulus compared with normal spleen. Significantly more animals without spleens developed bacteraemia (p = 0.02). Phagocytic activity of the upper splenic remnant was 89% that of normal spleen. Serum IgM concentrations without antigenic stimulus were 144, 138.2 (p = 0.6), and 86.2 (p < 0.001) mg/L; and with antigenic stimulus 263, 201.7 (p < 0.0001), and 98.1 (p < 0.0001) mg/L in groups 1, 2, and 3, respectively. The increase in serum IgM concentrations as a response to antigen was significant in the control (p < 0.0001) and in the partial splenectomy group (p < 0.0001), but not in the splenectomy group (p = 0.1). CONCLUSIONS: After reduction of its volume, the upper splenic remnant remained adequately supplied by the short gastric vessels. The upper part of the spleen preserved its normal histological architecture, had considerable phagocytic activity, possessed the ability to produce antibodies, and created a satisfactory immune response to antigenic stimulus. In rats, a considerable volume of functional and well perfused splenic tissue is preserved even after dividing the main vessels.

Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat?

Perforation and spillage of gallstones is a common occurrence in laparoscopic cholecystectomies. The long-term complications of these stones remains controversial. Experimental studies have been carried out to elucidate the outcome of intraperitoneal gallstones, but the chemical composition of these stones has not been considered in previous studies. In this study, we investigated the local effects of intraperitoneal gallstones in rats with respect to their chemical composition. Bile and gallstones were taken from human cholecystectomy specimens, and sent for bacteriologic and chemical analysis. Twenty cholesterol and 10 pigment stones were placed in the abdominal cavity of rats. Long-term local effects of gallstones were determined at the end of 3 months with macroscopic and microscopic examination. The fragments of two pigment stones were infected by Staphylococcus aureus. Five (17%) cholesterol stones were found free in the abdominal cavity, and 25 stones (83%) were wrapped with adjacent structures. Granuloma formation was found around 4 pigment stones (13% of all stones, 40% of pigment stones; p = 0.0077). We observed large granulomas and cutaneous fistula formation in two rats with infected pigment stones placed in the abdominal cavity. Histhopathologic examination also showed significantly severe inflammatory reactions secondary to pigment stones (p<0.001). In conclusion our findings revealed that chemical composition has a significant influence on the fate of intraabdominal gallstones, and infection may aggravate local reactions and complications. Based on our findings, laparoscopic retrieval of spilled stones whenever possible seems to be useful to prevent subsequent infectious complications and inflammatory reactions. Patients with retained intraperitoneal pigment stones after laparoscopic cholecystectomy must be followed up closely.

The inflammatory response to open tension-free inguinal hernioplasty versus conventional repairs.

BACKGROUND: The tension-free inguinal hernioplasty is now a popular method because of less postoperative disability and low recurrence rate. The laboratory evaluation of the inflammatory response to the injury is an objective approach to determine the stress status of a surgical procedure. The aim of this study is to evaluate and to compare inflammatory responses to open tension-free and conventional repairs of inguinal hernias. METHODS: Forty-eight male patients with primary indirect inguinal hernias were treated with elective operations, and separated into three groups according to surgical procedure: 12 pediatric patients treated with dissection of hernia sac in group 1, 16 adult patients with open tension-free hernioplasty in group 2, and 20 adult patients with conventional repairs in group 3. Ten healthy adult volunteers formed group 4 as control. The repair was performed with polypropylene mesh and suture as the Lichtenstein technique in group 2, and with polypropylene suture as one of Bassini, McVay, or Shouldice techniques in group 3. The inflammatory response was evaluated with serum interleukin-6 (IL-6) levels at 12 hours and serum C-reactive protein (CRP) levels at 48 hours postoperatively. Serum levels of IL-6 and CRP were measured in group 4 as control. Patient characteristics, operating time, and IL-6 and CRP levels were compared among the four groups. RESULTS: There were no significant differences in mean age and operating time between the two groups of adult patients with hernia repair. Mean serum IL-6 levels of 12.1 +/- 5.2 and 8.2 +/- 2.7 pg/mL, and CRP levels of 34.3 +/- 13.8 and 7.5 +/- 4 mg/L in pediatric and control groups, respectively, were significantly lower than in the other two hernia groups. Mean serum IL-6 levels were 58.9 +/- 25.4 pg/mL in group 2 (tension-free repair) and 44.3 +/- 18.1 pg/mL in group 3 (conventional repair) (P > 0.05). Mean serum CRP levels were 111.3 +/- 41.3 and 83 +/- 43.2 mg/L in groups 2 and 3, respectively (P > 0.05). The differences not being statistically significant, a similar and considerable inflammatory response was noted in patients with either prosthetic mesh repair or with conventional repairs of indirect inguinal hernias. CONCLUSIONS: The reinforcement of the posterior wall of the inguinal canal induces significant cytokine response regardless of tension-free or conventional repair. Open tension-free hernioplasty offered no advantages over conventional repairs from the standpoint of the inflammatory and acute phase response.

Small bowel volvulus: a common cause of mechanical intestinal obstruction in our region.

OBJECTIVE: To find out the incidence and causes of small bowel volvulus in our region, and to analyse the results of our management. DESIGN: Retrospective study. SETTING: Teaching hospital, Turkey. SUBJECTS: 38 Patients who had had no previous abdominal operations who were operated on for mechanical intestinal obstruction caused by small bowel volvulus. MAIN OUTCOME MEASURES: Incidence of small bowel volvulus, details of patients, treatments, complications, and outcome. RESULTS: Small bowel volvulus constituted 8%(38/466) of all cases of mechanical intestinal obstruction and 13%(38/292) of small bowel obstruction. Volvulus was primary in 18 (47%), and secondary in 20 (53%) patients. 33 Patients (87%) were male. The mean age of the whole group was 30 years, 42 and 19 in patients with primary and secondary volvulus, respectively (p=0.0005). The incidence of small bowel volvulus was 19%(27/143) in patients under 40 years, and 7%(11/149) in those over 40 years of age (p=0.005). Sixty percent of patients with secondary volvulus (12/20) were under 20 years of age compared with 17% of those with primary volvulus (3/18; p=0.009). The causes of secondary volvulus were Meckel's diverticulum in 14 patients (70%), and malrotation and ileosigmoid knotting in 3 patients each (15%). Segments of bowel were gangrenous in 12 patients (32%). Treatment was by simple untwisting in patients with viable segments of gut, or with resection of gangrenous segments and primary small bowel anastomosis. One patient died postoperatively of septic shock. CONCLUSIONS: Small bowel volvulus is a common form of intestinal obstruction in our region. It carries a high risk of gangrene of twisted segments of bowel. Fortunately perforation of small bowel is uncommon, and resection and primary anastomosis is a safe procedure in cases of necrosis. Today the outcome of such patients is satisfactory. Early and proper management is essential for a good outcome.

Blockade of transdiaphragmatic lymphatic absorption reduced systemic inflammatory response syndrome during experimental peritonitis: evaluation with body oxygen kinetics in rats.

OBJECTIVE: To assess the effect of blockade of transdiaphragmatic lymphatic absorption of infected peritoneal fluid on systemic inflammatory response syndrome during experimental peritonitis by evaluating body oxygen kinetics in rats. DESIGN: Randomised controlled experimental study. SETTING: Teaching hospital, Turkey. MATERIAL: 30 Wistar-albino rats, 10 in each group. INTERVENTIONS: Control group, sham laparotomy; peritonitis alone group, faecal peritonitis induced by caecal puncture; and lymphatic blockade and peritonitis group, transdiaphragmatic lymphatic absorption was blocked by fibrosis created by a sheet of braided polyester (Mersilene) mesh, and peritonitis induced with caecal puncture. MAIN OUTCOME MEASURES: Aerobic culture of peritoneal contents and blood. Arterial and mixed venous blood gas analysis, plasma lactate concentrations. Indicators of body oxygen kinetics were calculated from these variables. RESULTS: Bacterial peritonitis was detectable in all 20 animals in the experimental groups. Blood cultures grew pathogens in 9/10 animals in the peritonitis alone group and 4/10 in the lymphatic blockade group (p = 0.057). Among the measured blood gas variables there were significant differences in PvO2 (p = 0.006) and in PaCO2 (p = 0.02), and as indicators of tissue perfusion and acidosis there were significant differences in all calculated blood gas variables and in plasma lactate concentration (p = 0.0001) between the two experimental groups. Hypoxia as judged by the oxygen utilisation coefficient of over 0.5 and oxygen saturation of mixed venous blood of less than 50%, eight animals were hypoxic in the peritonitis alone group compared with one in the lymphatic blockade group (p = 0.006). CONCLUSION: Animals in which transdiaphragmatic drainage was obstructed had fewer positive blood cultures and better body oxygen balance during peritonitis, indicating that blockade of transdiaphragmatic lymphatic absorption of peritoneal contents reduced systemic inflammatory response syndrome.

Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon's clinical impression.

UNLABELLED: Diagnosis of acute appendicitis is established generally by the surgeon's clinical impression. Today, negative laparotomy rate because of clinical diagnosis is still 15 to 25 percent. PURPOSE: This study was designed to determine the accuracy of C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis and to compare it with the surgeon's clinical diagnosis. METHODS: One hundred eight consecutive patients were studied prospectively. Depending on results of the examination by a surgeon, patients underwent surgery for acute appendicitis. Serum CRP measurements were performed before the operations but were not taken into account for the decision of laparotomy to compare it with the surgeon's clinical diagnosis. RESULTS: Histopathologic findings confirmed acute appendicitis in 90 patients. Normal appendixes were removed in the remaining 18 patients. Mean serum CRP value was 5 (range, 0-12.6) mg/l in patients with normal appendix, 33.8 (range, 5-85.1) mg/l in patients with nonperforated appendicitis, and 128.5 (range, 79.2-230) mg/l in patients with perforated appendixes. These differences were highly significant (P < 10(-6)). Serum CRP levels were normal in three patients with acute appendicitis. Thus, the false-negative rate of CRP was 3 percent. Of 18 patients with normal appendectomy serum CRP levels were slightly elevated in two patients. We determined, therefore, a false-positive rate of CRP as 11 percent. CRP levels were false-negative in three patients and false-positive in two patients. Thus, CRP levels were true (positive or negative) in the remaining 103 patients. On the other hand, the diagnosis depending on surgeon's clinical impression was true in 90 patients and false in 18 patients. This difference was statistically significant (P = 0.0035). In the present study the sensitivity, specificity, and accuracy of serum CRP measurements were calculated as 93.5, 80, and 91 percent, respectively. CONCLUSION: We found that elevated serum CRP levels support surgeon's clinical diagnosis. We recommend CRP measurement as a routine laboratory test in patients with suspected diagnosis of acute appendicitis.