Management of intrabiliary ruptured hydatid disease of the liver.

BACKGROUND/AIMS: Intrabiliary rupture of hydatid cyst is an important complication of hydatid disease of the liver. The purpose of this study was to evaluate outcomes of patients with intrabiliary ruptured hydatid disease of the liver. METHODOLOGY: Two hundred and eleven patients were operated upon for hydatid cyst of the liver between 1990 and 1998 in our hospital. Twenty-four patients with intrabiliary rupture of hepatic hydatid cyst were retrospectively reviewed. RESULTS: Diagnosis of hydatid cyst was principally made using ultrasonography. We performed partial cystectomy + omentoplasty + transduodenal sphincteroplasty for 18 patients (75%). Daughter cysts and hydatid debris were found in common bile duct in 8 patients (33%). Internal opening of biliary fistula was found in 21 patients (87.5%). Morbidity rate was 12%. One patient died of unrelated causes. The average postoperative hospitalization period for the sphincteroplasty group was 7.6 days. CONCLUSIONS: Preoperative radiologic examination and laboratory values were not helpful to exclude an intrabiliary rupture of hydatid cysts in our patients. If bile stained cystic fluid is found, it is clear that a communication between hydatid cysts and the biliary tree exist. Transduodenal sphincteroplasty can be preferred in the management of intrabiliary ruptured hydatid disease because of short hospitalization, low morbidity, and ability to decompress intrabiliary pressure.

Evaluation of phagocytic function of macrophages in rats after partial splenectomy.

BACKGROUND: Understanding the immunologic properties of the spleen has enabled surgeons to practice splenic conservation surgery. If the upper pole of the spleen can be preserved solely on the upper short gastric vessels, will phagocytic function of macrophages in remnant splenic tissue be affected? The aim of this experimental study was to evaluate the phagocytic function of macrophages in partially resected spleens, with hilar excision preserving the short gastric vessels. STUDY DESIGN: Forty-eight female Wistar albino rats were divided into four groups. Groups 1 and 2 underwent sham operations and groups 3 and 4 underwent partial splenectomy. One milliliter of sodium chloride 0.9% was injected into the abdomen of the rats in groups 1 and 3 and 1 mL of Streptococcus pneumoniae type III as an antigenic stimulus was injected into the abdomen of the rats in groups 2 and 4, 6 weeks after the first operation. Forty-eight hours later, relaparotomy was performed in all animals. India ink was used to determine the capacity of uptake in the splenic phagocytes. To evaluate the phagocytic function of the splenic tissues, histologic examinations were performed according to a macrophage grading system. RESULTS: All spleens in all four groups were stained black after injection of India ink. Phagocytic activity of macrophages was reduced in the partially splenectomized groups, compared with intact spleen groups (group 3 versus group 1; p < 0.0001, group 4 versus group 2; p < 0.0001). There was a significant difference between groups 1 and 2 according to phagocytic function of macrophages (p = 0.0121). Also, after Streptococcus pneumoniae type III injection as an antigenic stimulus in group 4, we found that the phagocytic functions of macrophages increased compared with those of the sodium chloride 0.9%-injected group 3 after partial splenectomy (p < 0.0001). CONCLUSIONS: Phagocytic function of macrophages in rats decreased after partial splenectomy. Nevertheless, the remnant spleens in rats could be stimulated when challenged with an antigenic stimulus.

Complete remission of the liver metastases of anorectal malignant melanoma with regional chemotherapy: a case report.

The prognosis of anorectal malignant melanoma is very poor. We present a 48-year-old male patient with anorectal malignant melanoma and multiple liver metastases who underwent abdominoperineal resection. A port system was implanted to the gastroduodenal artery for regional chemotherapy for liver metastases. Histopathological findings of tumor were 5 cm diameter and 2 cm depth, invading to the external sphincter. Both regional chemotherapy and immunotherapy were initiated 4 weeks postoperatively. The immunochemotherapy regimen included cisplatin (via port system) 50 mg/m2 once in 2 weeks, x 8 cycles, alpha-interferon 5 x 10(6) U subcutaneously on days 1-7 in 4 weeks, x 8 cycles, interleukin-2 9 x 10(6) U subcutaneously on days 5-9 in 4 weeks, x 8 cycles. Computed tomography scan was taken after the 2nd and 4th cycles of chemotherapy and the tumor had not responded to chemotherapy. Dacarbazine 200 mg/m2 intravenously on days 1-5 in a month, x 4 cycles, was added to the previous immunochemotherapy regimen. Computed tomography and magnetic resonance imaging scans were taken on the 10th and 12th months after operation, respectively, no evidence of metastases in the liver was noted. No case of complete remission of liver metastases of anorectal malignant melanoma with regional intraarterial chemotherapy and systemic immunochemotherapy has been previously reported in the literature.

Hemodynamic stability is the most important factor in nonoperative management of blunt splenic trauma.

Since January 1998, non-operative management of blunt splenic trauma has become the preferred method for the selected paediatric and adult patients in our clinic. Of the 26 patients who were admitted to our clinic because of blunt splenic trauma between January 1998 and May 2000, 20 were elected for non-operative management according to our protocol which was primarily based on hemodynamic status regardless of the age and grading of the injury. Diagnostic computed tomography (CT) was obtained in the patients with non-operative management. Non-operative management rate was 76.9% for patients with blunt splenic trauma (83.3% and 71.4% for the paediatric and adult patients, respectively). All of these cases were managed conservatively without any complication and no mortality was observed. Six patients required emergent surgical exploration based on preoperative evaluation. In all of these 6 cases, associated injuries were present. No significant differences were found with regard to the age of operative and non-operative management groups (p = 0.421). The mean operative splenic injury grade was 3 in the patients who underwent surgery, and the mean injury grade based on CT scan was 2.6 in the patients who were managed conservatively (p = 0.572). The mean duration of hospitalisation in the patients with operative and non-operative management groups were 7.6 and 8.6 days, respectively (p = 0.572). The mean unit of blood transfusion in the patients with operative and non-operative management groups were 1.1 and 0.6, respectively (p = 0.453). Our data revealed that hemodynamic stability is the most important factor which could effect the selection of patients for non-operative management outcome regardless of the patient age and computed tomography scan grading of the injury.

Hypertonic saline prevents early bacterial translocation in hemorrhagic shock.

The most appropriate solution for volume replacement in hemorrhagic shock is controversial; however, hypertonic saline (HTS) solutions have recently gained widespread acceptance. In this study, various solutions were used to resuscitate rats in hemorrhagic shock, and their impact on the extent of bacterial translocation was investigated. Rats were bled to a mean arterial blood pressure of about 35 mmHg which was maintained for 30 min. They were then randomized into six groups. Blood pressure was found to be regulated by blood + lactated Ringer's solution (LR) and HTS + LR, but no significant improvement was observed in the control and LR groups. Groups II (7.5% HTS + 60 ml/kg LR) and IV (60 ml/kg LR + autologous blood) had a significantly better result than groups I (7.5% HTS), III (60 ml/kg LR), and IV (P < 0.05), among which no statistically different results were seen (P > 0.05). While no organisms were isolated from the mesenteric lymph nodes in the sham group, the rates of positive culture were 12.5%, 12.5%, 50%, 62.5%, and 62.5% in groups I, II, III, and the control group, respectively. Escherichia coli was the most commonly isolated organism. HTS + LR was demonstrated to be effective for decreasing the rate of early bacterial translocation to mesenteric lymph nodes and also for restoring the mean arterial pressure.