Reduced-Size Left Lateral Segment Grafts in Infants Weighing <10 kg.

BACKGROUND: Live donor liver transplantation for infants weighing <10 kg has unique complexities, as patient/graft size discrepancies may cause vascular perfusion deficiencies. Failure of the abdominal closure further complicates this already challenging procedure. To overcome these potential problems, several techniques for graft size reduction-either anatomic or nonanatomic-have been proposed in the literature. Technically easier and less time-consuming, nonanatomic size reductions have the advantage of avoiding the risk of injury to the portal pedicle. This study aimed to evaluate and compare the effects of nonanatomic graft size reduction in infants weighing <10 kg with a large estimated preoperative graft recipient weight ratio. METHODS: We enrolled 106 infants weighing <10 kg. Of these infants, 50 received reduced-size grafts. The outcomes were compared between the groups. RESULTS: No difference was observed between the groups according to survival and vascular or biliary complications. None of the patients required an open abdomen or mesh closure. CONCLUSION: Nonanatomic size reduction of left lateral segment grafts can be safely applied without compromising vascular supply, graft function, and patient survival with comparable vascular and biliary complication rates. This technique is safe and efficient in overcoming the complications caused by large-for-size syndrome in infants weighing <10 kg.

Portal Vein Pull-Through Technique and Thrombectomy for Extensive Portal Vein Thrombosis.

BACKGROUND: Herein, a different technique is presented describing complete dissection of the entire portal vein (PV), superior mesenteric vein (SMV), and splenic vein, thus enabling a complete thrombectomy without the risk of uncontrolled hemorrhage due to blind thrombectomy. METHODS: In cases where a thrombectomy would not be an option because of extensive thrombosis involving the confluence of the PV and SMV, small branches of the SMV, including the inferior mesenteric vein, were divided. Both the SMV and splenic vein were encircled separately. Then, the side branches of the PV above the pancreas, left gastric vein on the left side, and superior pancreatoduodenal vein on the right side were divided. The lateral and posterior part of the PV were dissected within the pancreas both from above and below, allowing the main PV completely free from attachments. At this point, the splenic vein and SMV were clamped, and the main PV was divided above the pancreas and then pulled back through the pancreatic tunnel. The thrombus was easily dissected of the vein under direct visualization, and afterward the PV was redirected to its original position. Then, the liver transplant was carried out in a regular fashion. RESULTS: This technique was applied to 2 patients. The first was a 43-year-old man who underwent a right lobe living donor liver transplant because of hepatitis B virus-related cirrhosis. The patient is still alive and well with stable liver function after 15 years of follow-up. The second was a 69-year-old woman who underwent a right lobe living donor liver transplant because of hepatitis C virus and hepatocellular carcinoma. She survived the procedure and her liver function was entirely normal afterward. She died of pneumonia and sepsis 5 months after transplant. CONCLUSIONS: This technique enables complete dissection of the entire PV, SMV, and splenic vein. Thus, complete thrombectomy under direct visualization without the risk of uncontrolled hemorrhage can be performed.

Aplastic Anemia Frequency and Management in Pediatric Liver Transplantations Due to Non-A-E Hepatitis.

BACKGROUND: Hepatitis-associated aplastic anemia (HAAA) is a rare complication that presented with bone marrow failure after acute hepatitis. HAAA usually occurs in adolescent men within 1-6 months following hepatitis. Most of HAAA's etiology has non-A-E viral hepatitis. METHODS: Our retrospective study included patients with acute fulminant hepatitis who had been treated in Ege University Pediatric Gastroenterology, Hepatology and Nutrition Department and Izmir Kent Hospital Clinical, laboratory, and epidemiological data of the patients were collected from the files. RESULTS: In this study, 499 children underwent liver transplantation (LT) in two pediatric transplantation centers. Sixty-eight (13.6%) out of 499 patients, underwent liver transplantation due to fulminant hepatic failure (FHF). Therefore, a total of 64 patients (34 girls, 30 boys) with a diagnosis of FHF have included in the study. Thirty-two (50.0%) of 64 FHF were due to non-A-E hepatitis and 4 out of the 64 patients (6.2%) with FHF developed HAAA. All of the patients received prednisolone as immunosuppression treatment after LT. Three patients were also given Tacrolimus and 1 received an additional mycophenolate mofetil. One of the patients was given prednisolone and cyclosporine treatment without tacrolimus. Bone marrow transplantation was performed in 1 patient (25.0%). Two of the patients received immunosuppressive treatment including rabbit-derived anti-thymocyte globulin, cyclosporine, and initially prednisolone. CONCLUSION: In children who underwent liver transplantation for non-A-E FHF are at high risk to develop aplastic anemia. The clinicians should be alert after orthotropic liver transplantation patient could develop aplastic anemia and early treatment with immunosuppressive therapies result in a more successful outcome.

Bilioenteric Reconstruction Techniques in Pediatric Living Donor Liver Transplantation.

Biliary complications (BCs) are still a major cause of morbidity following liver transplantation despite the advancements in the surgical technique. Although Roux-en-Y (RY) hepaticojejunostomy has been the standard technique for years in pediatric patients, there is a limited number of reports on the feasibility of duct-to-duct (DD) anastomosis, and those reports have controversial outcomes. With the largest number of patients ever reported on the topic, this study aims to discuss the feasibility of the DD biliary reconstruction technique in pediatric living donor liver transplantation (LDLT). After the exclusion of the patients with biliary atresia, patients who received either deceased donor or right lobe grafts, and retransplantation patients, data from 154 pediatric LDLTs were retrospectively analyzed. Patients were grouped according to the applied biliary reconstruction technique, and the groups were compared using BCs as the outcome. The overall BC rate was 13% (n = 20), and the groups showed no significant difference (P = 0.6). Stricture was more frequent in the DD reconstruction group; however, this was not statistically significant (P = 0.6). The rate of bile leak was also similar in both groups (P = 0.6). The results show that the DD reconstruction technique can achieve similar outcomes when compared with RY anastomosis. Because DD reconstruction is a more physiological way of establishing bilioenteric integrity, it can safely be applied.

Solid pseudopapillary neoplasms of the pancreas: Case series with a review of the literature.

BACKGROUND/AIMS: The solid pseudopapillary neoplasms are quite rare tumors of the pancreas, comprising roughly 1-2% of all pancreatic neoplasms. It has a low malignant potential and usually affects young females. Despite increasing number of articles in the last decade, there is still debate on the pathogenesis, malignant potential and optimal surgical strategy for the solid pseudopapillary neoplasms. MATERIALS AND METHODS: Medical recordings of 326 patients who were operated due to pancreatic mass were retrospectively analyzed. Patient demographics, presenting symptoms, surgical and pathologic characteristics of the tumor, postsurgical course, long-term survival, and other relevant data were extracted from patients' charts. RESULTS: Majority of the patients were female in consistency with the classic data in the literature. All the patients underwent curative intent resections. Tumors were commonly localized in the tail of the pancreas making distal pancreatectomy the most commonly performed surgical procedure. Mean tumor diameter was 5.8 centimeters with tumor sizes ranging from 1 to 19 cm. CONCLUSION: The solid pseudopapillary neoplasms of the pancreas is a rare tumor with low malignant potential, which is more common in females of reproductive age, with abdominal pain being their most common presentation. The short-term outcomes in patients following surgical R0 resection are excellent. However, proximal placement of the tumor and female gender may have slightly worse prognosis. We hope that our findings from a series of patients represent a contribution to the existing literature on SPN, and authors declare their willingness to provide further details for future meta-analyses.

Hepatic Venous Outflow Reconstruction Directly Into the Right Atrium.

OBJECTIVES: Living-donor liver transplant for BuddChiari syndrome is particularly challenging because of the need for venous outflow reconstruction as grafts from living donors lack vena cava. In addition, recipient vena cava may be thrombotic and fibrotic to such an extent that it would not allow graft venous outflow reconstruction. Under these circumstances, the right atrium provides an easily accessible alternative for venous outflow reconstruction, omitting the need for vena cava replacement. MATERIALS AND METHODS: Data from 3 patients who were treated using this technique were collected and evaluated with regard to surgical technique and outcomes. RESULTS: All patients were alive without vascular complications after a mean follow-up of 67 months. The applied surgicaltechnique was similar except with regard to vena cava preservation. CONCLUSIONS: During the natural course of the disease, venous collaterals form as chronic thrombosis extends into the vena cava. The vena cava can be safely resected in these patients to facilitate hepatectomy through dense adhesions, which is another common clinical problem in this disease. Consequently, venous outflow reconstruction to the right atrium creates the feasible opportunity of draining the graftliver without having to replace the vena cava.

Live donor liver transplantation for type 1 tyrosinemia: An analysis of 15 patients.

Type 1 tyrosinemia is a rare metabolic disorder of the tyrosine degradation pathway. Due to the rarity of the disease, the best evidence literature offers is limited to guidelines based on expert opinions and optimal treatment is still a debate. LT serves as a definitive treatment of the defective metabolic pathway in the liver along with other serious disease manifestations such as LF and HCC. Nitisinone is a relatively new agent that is currently recommended for the medical management of the disease. Its mechanism of action is well understood, and efficacy is well established when started presymptomatically. This study aims to evaluate outcomes of 15 patients with type 1 tyrosinemia who underwent LT in nitisinone era and discuss its effect on prevention of HCC. A LT database of 1037 patients was reviewed. Data from 15 patients with type 1 tyrosinemia were retrospectively analyzed. All the patients except one were treated with nitisinone prior to LT. Most common indications for LT were LF and suspicious nodules. Seven patients had HCC. Mortality rate was 20% (n = 3). Nitisinone treatment has opened new horizons in the management of type 1 tyrosinemia, but LT still remains the only option for the patients developing LF and in the event of HCC. Neonatal screening programs utilizing blood succinyl acetone as the marker should be encouraged especially in the countries, such as Turkey, with high prevalence of consanguineous marriages.

Prognostic Value of Metastatic Lymph Node Ratio in Pancreatic Cancer.

Lymph node involvement in pancreatic adenocancer is one of the strongest predictors of prognosis. However, the extent of lymph node dissection is still a matter of debate and number of dissected nodes varies widely among patients. In order to homogenize this diverse group of patients and more accurately predict their prognosis, we aimed to analyze the effect of metastatic lymph node ratio as an independent prognostic factor. We retrospectively analyzed medical recordings of 326 patients with pancreatic cancer who were treated in a tertiary medical oncology center over a 10-year period. Both in univariate and multivariate analyses, metastatic lymph node ratio proved to be a strong predictor of prognosis which was unaffected from heterogeneity of our patient population and can be used to facilitate predict prognosis of patients who underwent lymph node dissection to various extents and with future studies it can emerge as a successful tool for creating prognostic subgroups of the disease.

Retrospective evaluation of candidemic patients among general surgery department in a tertiary care university hospital.

OBJECTIVES: Candida species are among the most important causes of hospital acquired blood borne infections, and with high rates of mortality and morbidity, these infections are still a major problem today. History of gastrointestinal surgery, administration of total parenteral nutrition and/or wide spectrum antibiotics and immune suppression following organ transplantations are considered serious risk factors for these infections. This study aimed to evaluate the patients from our general surgery department with diagnosed candidemia; by means of strain, treatment and prognosis. MATERIAL AND METHODS: Patients with positive blood cultures for Candida species who were treated in the wards and Ege University Faculty of Medicine general surgery department of surgical intensive care units of our between 2012 and 2017 were retrospectively analyzed by means of strain, treatment and prognosis. RESULTS: A total of 50 patients were enrolled in the study. Mean age was 58.96 years and 54% of the patients were female. There were nine patients with organ transplantation (four liver and five kidney transplantations), six with intestinal perforation and three with anastomotic leakage. Isolated strains were Candida albicans (36%; 18/50), Candida tropicalis (14%; 7/50), Candida glabrata (12%; 6/50), Candida parapsilosis (8%; 4/50), Candida kefyr (6%; 3/50), Candida krusei (4%; 2/50), Candida pulcherrima (2%; 1/50), Cryptococcus neoformans (2%, 1/50), Geotrichum capitatum (2%, 1/50), Candida spp. (unidentified, 14%; 7/50) with decreasing frequency. The highest antifungal sensitivity rates (> 90%) were measured for amphotericin B, voriconazole and echinocandins among all isolates. One-month mortality rate was 43.4% (20/46). Documented eradication was achieved among 24 of the 33 patients who had control blood culture samples (72.7%), and mean eradication time was 7.6 days. Echocardiography was performed in 14% (7/50) and ophthalmic examination in 8% (4/50). CONCLUSION: Although C. albicans appears to be the dominant strain in patients with candidemia, frequencies of other strains are increasing. Early diagnosis and treatment of patients with candidemia is of vital importance due to high mortality and morbidity rates.

Unexpected Benefit of the Positron Emission Tomography/Computed Tomography Using 18F-Fluorodeoxyglucose: Report of a Case.

The positron emission tomography/computed tomography (PET/CT) has been a new tool utilized in the diagnosis and staging of various cancers. However, common worldwide utilization of the PET/CT includes some economic, legal, and ethic controversies. Although PET/CT scanning can detect colorectal premalignant lesions in an early treatable stage, most governments' health care system does not pay for it as a screening test because of its economic burden. Thus, people are forced to make vital decisions about their health because of health policies of their governments. Here, we present an unusual case and discuss the utilization of PET/CT for detection of incidental neoplasms.

Diverted sleeve gastrectomy with ileal transposition in overweight, obese, and morbidly obese patients with type 2 diabetes: results of 1-year follow-up.

BACKGROUND: Bariatric surgery is an effective intervention for morbidly obese individuals, and it normalizes the level of glycemia in the majority of patients with type 2 diabetes mellitus (T2DM). OBJECTIVES: The primary aim of the study was to examine the efficacy of diverted sleeve gastrectomy with ileal transposition on weight loss and glycemic control in overweight, obese, and morbidly obese T2DM patients. The secondary aim was to examine the relationship between the effect of surgery and body mass index (BMI). SETTING: Metabolic surgery clinic. METHODS: This study was performed between October 2011 and August 2014, and mean duration of follow-up was 1 year. A total of 131 patients with T2DM were included. Ileal transposition with sleeve gastrectomy were performed in all patients. Each patient received a standard mixed meal tolerance test; plasma glucose, C-peptide, and insulin concentrations were measured before and 1 hour after the test. Postoperative alterations in BMI were noted. RESULTS: Mean BMI decreased from 33.1±.5 to 23.5±.2 kg/m(2) at 1 year, with the magnitude of weight loss correlating with baseline weight (P<.0001). There were marked decreases in fasting plasma glucose concentration and mean glycosylated hemoglobin levels at 1 year. Neither the decrease in fasting plasma glucose or glycosylated hemoglobin correlated with the decrease in weight. The homeostasis model assessment index decreased from 9.6±1.2 to 2.2±.2, P<.0001, and the Matsuda index for insulin sensitivity increased from 2.2±.2 to 7.8±.4, P<.0001. Despite the improvement in insulin sensitivity, surgery caused a 4-fold increase in insulin secretion (P<.01). CONCLUSION: Diverted sleeve gastrectomy with ileal transposition is effective in glycemic control in patients with T2DM; however, this was not dependent on preoperative BMI values.

A Retrospective 3D Radiologic Analysis of 52 Patients with Mandible Fractures.

When fractured, mandible angulates. For better preoperative evaluation, movements of fractured mandibular segments should be documented in x-, y-, and z-axes. This article quantitatively evaluates the pattern and degree of the angulation. Fifty-two patients with mandible fractures were involved in this study. After defining a three-dimensional (3D) coordination system consisting of the x-axis (the axis directed from the medial to lateral side of the skull), y-axis (directed from the inferior to superior side), and z-axis (directed from the posterior to anterior side), the degree with which the fractured mandible angulated around each of these axes was measured using 3D graphic software. The tendency of the angulation was compared between the three axes. Frequency of complications, operation times, maxilla mandibular fixation (MMF) need, and epidemiologic data were compared with the angulation results. Angulation around the x-axis was the most frequent with a 55.8% incidence, followed by a substantial margin of angulation around the y-axis with a 21.2% incidence; angulation around the z-axis was rare, with an incidence of 15.4%. Furthermore, the degree of z-axis angulation was minor compared with x- and y-axes angulations. There were statistically increased rate of complications, operation time, and MMF need in patients with more than 10 degrees of angulation in any case. Operation time and complication rates are also increased in patients with internal rotation of the proximal segment. Preoperative evaluation of mandible fracture angulation degree is useful for determining postoperative complication rates, MMF need, and operative challenge. This finding is helpful for effective performance to reposition the fractured mandible.

Recurrent pilonidal sinus: lay open or flap closure, does it differ?

Treatment options of pilonidal sinus, which has high recurrence rates, is still controversial. In this study, we aimed to analyze for possible factors affecting recurrence. Forty-one patients with recurrent pilonidal sinus were included in this study. Of them, 33 were male and 9 were female (mean age, 24.9 years; age range, 16-42). Factors (i.e., risk factors) were detected in 32 patients. Excision-secondary healing and lay open was performed on 30 of the patients admitted with recurrence. Excision and flap closure was applied on 11 patients. Our recurrence rate was 9.7%. The recurrence rate of our study is compatible with the literature. Comparative studies are needed to determine the appropriate method to decrease recurrence rate.

The functional results of acute nerve grafting in traumatic sciatic nerve injuries.

BACKGROUND: The sciatic and peroneal nerves are the most frequently injured in lower extremities, followed by tibial and femoral nerves. The aim of this study is to evaluate the functional results of acute nerve grafting in traumatic sciatic nerve injuries. METHODS: A total of 9 patients with sciatic nerve defect were treated with primary nerve grafting. The mean age was 31.7 years. The etiologic factors were gunshot wounds, traffic accident, and penetrating trauma. RESULTS: All of the patients had sciatic nerve defects ranging from 3.4 to 13.6 cm. The follow-up period ranged between 25 and 84 months. The tibial nerve motor function was "good" or "very good" (M3-M4) in 5 patients (55.6%). The plantar flexion was not sufficient for the rest of the patients. The peroneal nerve motor function was also "good" and "very good" in 3 patients (33.3%). CONCLUSION: The functional results of the acute nerve grafting of the sciatic nerve within the first week after the injury are poorer than reported in the related literature. This protocol should only be applied to select patients who have adequate soft tissue coverage and healthy nerve endings.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature.

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

[Necrotizing fasciitis: diagnosis, treatment and review of the literature]. / Nekrotizan fasiit: Tani, tedavi ve literatürün gözden geçirilmesi.

BACKGROUND: Necrotizing fasciitis (NF) is characterized by rapidly spreading necrosis of the soft tissue and fascia. It is rare, but can be fatal if not managed properly. The aim of this study was to discuss the morbidity and mortality in NF patients in terms of evaluating early diagnostic techniques and reconstructive options. METHODS: Sixty-eight patients (59 male, 9 female; mean age 55.9 years; range 28 to 88 years) with localized NF who were treated between 2000 and 2010 were assessed retrospectively for age, sex, localization, time elapsed between onset of symptoms and diagnosis, predisposing factors, characteristics of tissue defects, isolated microbiological agents, surgical intervention, complications, and mortality rate. RESULTS: In 52 patients (76.4%), comorbidities such as diabetes, obesity, smoking, and corticosteroid use were present. The most common localization was the perineum and inguinal region (n=48, 70.5%). Time elapsed between onset of symptoms and diagnosis was 6.2 days (1-12 days). The mean size of tissue defect after the first debridement procedure was 54.2 cm2 (28-82 cm2). The most common isolated microbiological agents were as follows: Escherichia coli, Enterococci, and Pseudomonas aeruginosa. Polymicrobial infections were encountered in 54 patients (79.4%). The most common reconstructive procedures were fasciocutaneous flap + split-thickness skin grafting (n=39, 57.3%). No major complication was observed; minor complications included wound dehiscence and partial graft loss. The mortality rate was 13.2% (n=9). CONCLUSION: The early diagnosis of NF may be lifesaving. When NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.