Acar Tuzuner

Laparoscopıc Fundoplication with Prosthetic Hiatal Closure

BackgroundDespite 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.MethodsA 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.ResultsWe 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.ConclusionThe 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.

The impact of two arterial catheters, different in diameter and length, on postcannulation radial artery diameter, blood flow, and occlusion in atherosclerotic patients.

PurposeArterial cannulation is a common intervention in anesthesia practice. However, the success rates and complications of radial arterial cannulation with 20-G or smaller catheters in patients with atherosclerosis have been underevaluated. The aim of this prospective randomized study was to compare the efficacy of and complications with 20- and 22-G catheters for radial arterial cannulation in atherosclerotic patients.MethodsThirty patients with atherosclerosis, American Society of Anesthesiologists (ASA) III–IV, undergoing general anesthesia were enrolled in the study. Radial artery cannulation was performed in group 20G (n = 15) with a 20-gauge (20 × 1.1 × 33 mm; flow, 61 ml·min−1) catheter and in group 22G (n = 15) with a 22-gauge (22 × 0.9 × 25 mm; flow, 36 ml·min−1) catheter. Radial artery systolic blood flow (SBF) and radial artery diameter (RAD) were assessed by a Doppler ultrasound probe before cannulation and 24 h after decannulation for vascular complications. The number of puncture attempts, arterial blood gas samples, and manual flushes; total heparinized solution consumption; duration of cannulation; decannulated radial arterial systolic blood flow; postcannulation RAD; and vascular complications such as occlusion, hematoma, pseudoaneurysm, bleeding, and thrombosis were noted. The Mann Whitney U-test, χ2 test, and one-sample t-test were used. Values are expressed as medians and quartiles and P < 0.05 was considered as significant.ResultsThe number of puncture attempts was greater in group 20G (range, 1 to 4) than in group 22G (range, 1 to 2; P = 0.02). In group 20G patients, postoperative RAD was larger than preoperative RAD (P = 0.02) and postoperative SBF was lower than preoperative SBF (P = 0.03). In group 22G patients postoperative SBF was higher than preoperative SBF (P = 0.03), while there was no significant difference between preoperative and postoperative RAD. The occlusion rate of atherosclerotic radial arteries was 6% with the 22-gauge catheter and 26% with the 20-gauge catheter (P = 0.02).ConclusionA 22-gauge catheter for radial arterial cannulation in patients with atherosclerosis provides unchanged postcannulated radial artery diameter, decreases postcannulation complications, and improves the first-attempt success rate.

Prevention of Surgical Site Infection After Open Prosthetic Inguinal Hernia Repair: Efficacy of Parenteral Versus Oral Prophylaxis with Amoxicillin-Clavulanic Acid in a Randomized Clinical Trial

The aim of this prospective study was to compare the efficacy of oral versus parenteral prophylactic amoxicillin–clavulanic acid for preventing surgical site infection after open prosthetic mesh repair of inguinal hernia. A total of 480 inguinal-hernia patients were randomly assigned to two groups. Group I (n = 240) received 1.313 g oral amoxicillin–clavulanic acid 2 hours before operation, and group II (n = 240) received 1.2 g of the same drug combination intravenously approximately 30 minutes before surgery. Patients were examined four times during 1 year of follow-up (at 7–10 days, 4–6 weeks, 6 months, and 12 months postoperation), and data related to surgical site infections were collected. Seventy-two patients were excluded due to confounding factors during and after the operation. There were no statistically significant differences between group I (final n = 208) and group II (final n = 200) with respect to age, sex distribution, body mass index, American Anesthesiology Association grade, frequencies of different hernia types, duration of surgery, and the experience levels of the principal surgeon in the operations. One of the 208 (0.5%) patients in group I and 3 of the 200 (1.5%) patients in group II developed superficial surgical site infections (p > 0.05). None of the infections required mesh removal. There were no deep surgical site infections in either group, and there was one case of hernia recurrence in each group. For patients undergoing open prosthetic repair of inguinal hernia, oral amoxicillin–clavulanic acid is safe, significantly less costly, and equally effective in preventing surgical site infection as the same dose given parenterally.

Low-Density Lipoprotein Oxidizability and the Alteration of Its Fatty Acid Content in Renal Transplant Recipients Treated With Cyclosporine/Tacrolimus

Renal transplantation is widely used to treat patients with end-stage renal disease. Atherosclerosis is an important posttransplantation risk factor for renal transplant recipients. Subsequent to transplantation low-density lipoprotein (LDL) particles become susceptible to oxidative modification, which results in atherosclerosis. Therefore, the aim of our study was to investigate differences in the susceptibility of LDL particles to oxidation by analyzing LDL fatty acid levels among renal transplant recipients. The changes in lag phases and fatty acid levels of LDL were observed over 4 months among renal transplant recipients treated with Cyclosporine (CsA; n = 7) or Tacrolimus (FK-506; n = 9). We also analyzed cholesterol and triglyceride levels of patients and healthy controls. The lag phase at the 60th day after transplantation was significantly shorter than the results either before transplantation or among control subjects. In conclusion, a similar decrease in lag phase was observed in both above groups, but the FK-506-treated group showed a better lipid profile than the CsA-treated group.

The Effect of Hyaluronan-Based Agents on Adhesion Formation in an Intraabdominal Sepsis Model

Because of the technical difficulty during subsequent surgical intervention, adhesion remains the mostimportant predictor of outcome in the staged procedures following emergent colorectal surgery. Theaim of this study was to assess the long-term effects of hyaluronan (HA)-based adhesion barriers3 months following the infectious insult to the peritoneal cavity. Wistar albino rats were divided intothree sham and four infectious groups, each consisting of 20 rats. Sham groups consisted of a controlgroup (I), which had undergone manipulation of the cecum in the first operation and saline irrigationfollowing the cecal resection in the second operation; an HA-based bioresorbable membrane (BM)group (II), in which 20 × 20- and 35 × 25-mm pieces of HA-based bioresorbable membrane wereplaced over the cecectomy area and under the midline incision, respectively, with other conditions thesame as for the control (I) group; and an HA-based solution (S) group (III), where HA solution wasused as an irrigation solution, with other conditions the same as for the control group (I). Infectiousgroups consisted of a septic group (IV), which had undergone cecal ligation and puncture in thefirst operation and saline irrigation following the cecal resection in the second operation; a sepsis C HA-BM group (V), in which two sheets of membrane were applied, with other conditions the sameas for the septic group (IV); a sepsis C HA-S group (VI), in which HA solution was used as anirrigation solution, with conditions otherwise the same as for the septic group (IV); and a sepsis C HA-BM C HA-S group (VII), where HA solution was used as an irrigation solution and two sheets ofmembrane were applied, with other conditions the same as for the septic group (IV). At the end of the3-month period, mortality, septic complications, and intraabdominal adhesions (adhesion scores andadhesion tensile strength measurements) were recorded. Significantly denser adhesions were foundin the septic group (IV) when compared to the others ( P < 0:001). HA-S significantly reduced notonly the incidence of adhesion but also the adhesion tensile strength in infectious groups ( P < 0:001compared to the sepsis group). However, HA-BM significantly reduced adhesion tensile strengthonly. Irrigation of the peritoneal cavity with HA-S may prove to be useful to shorten the reversaltime period and decrease morbidity following staged procedures for intraabdominal sepsis.

Pure Laparoscopic Versus Open Live Donor Nephrectomy: Evaluation of Health Survey and Graft Functions

BACKGROUND Laparoscopic donor nephrectomy (LDN) has become the gold standard in many kidney transplantation centers seeking to increase the number of potential live donors. This study was designed to compare the health surveys and graft functions between LDN and open donor nephrectomy (ODN). METHODS We retrospectively analyzed all patients who underwent donor nephrectomy between December 2005 and September 2009 who had at least 1 year of follow-up. We reviewed demographic data, operative time, warm ischemia period, graft function, and quality of life. RESULTS Among the 132 cases, 98 were pure LDN and 34 were ODN. Demographic data were similar in both groups. Operative times were significantly longer in the ODN group but warm ischemia times significantly longer in the LDN group. However, graft functions were similar in both groups. There was 1 graft loss due to arterial thrombosis of the transplanted kidney among the LDN group. Short-Form 36 health survey scores were similar except for the role-physical subscale. CONCLUSION Although we failed to observe a significant difference between ODN and LDN as far as the quality of life and graft functions were concerned, the previously documented advantages of laparoscopy with similar operative results suggest? LDN to be the gold standard for this procedure in our institution.

Living-Donor Hepatectomy

BACKGROUND Organ transplantation from deceased donors is still far below the need. Because of this deficiency, liver transplantations are performed mostly from live donors in many transplant centers in our country. Living-donor liver transplantation (LDLT) has evolved dramatically over the past decade. The aim of this study was to present our clinical experience with living-donor hepatectomy. METHODS We retrospectively analyzed all patients who underwent donor hepatectomy between March 2000 and September 2010. We reviewed demographic data, operation type, operation and cold ischemia times, duration of hospital stay, and postoperative complications. RESULTS During the study period, 140 living donors underwent operations for liver transplantation. We performed 108 right hepatectomies, 17 left hepatectomies, and 15 left lateral hepatectomies. The mean age of the donors was 30.8 years. There was no operative or postoperative mortality. Overall morbidity rate was 13.57% (n = 19). Nine patients had biliary leakages, 4 biliomas; 2 urinary tract infections, and 1 each inferior vena caval injury, pneumonia, portal vein thrombosis, and acute tubular necrosis. Reoperation was not required in any of these patients. CONCLUSIONS Living-donor liver transplantation is a valuable alternative for patients awaiting a cadaver organ. Live-donor hepatectomy can be performed with low morbidity. The greatest disadvantage of this procedure is the risk of the surgical operation for the individual who will experience no medical benefit from this procedure.

Single Stapler Technique in Laparoscopic Donor Nephrectomy

BACKGROUND Laparoscopic donor nephrectomy (LDN) is usually performed with at least 2 separate vascular staplers for division of the renal artery and vein. However, we used a single stapler regardless of the number of renal arteries and veins. Furthermore, the graft was quickly retrieved by hand without using an extraction bag using our technique. Herein we have presented our experience with LDN of grafts with single or multiple renal arteries and/or veins using a single stapler and hand removal. METHODS We reviewed demographic data, operative and warm ischemia times, postoperative complications, and graft function. RESULTS Between December 2005 and September 2009, we performed 85 cases with 1 renal artery (group LDN-1), 8 cases with two renal arteries (group LDN-2), and 5 cases with 3 or more renal arteries (group LDN-3). The demographic data among the groups were similar. The mean operative time was significantly longer among groups LDN-2 (100.3 ± 9.5 minutes) and LDN-3 (120.6 ± 10.3 minutes) compared with LDN-1 (76.1 ± 9.3 minutes; P < .001). Similar results were observed with respect to warm ischemia times. There were no significant differences related to graft function and outcomes among these groups. CONCLUSION The single stapler and hand removal technique was safe, technically feasible, and cost effective regardless of the number of renal arteries and veins. This technique removes the necessity of additional staplers and extraction bags, lowers the operative and warm ischemia times, and thus decreases the cost.

Endoscopic treatment of biliary complications following liver transplantation

BACKGROUND/AIMS The aims of the present study were to review biliary complications following liver transplantation in a single-center experience, to identify the factors associated with biliary complications, and to evaluate the success of endoscopic and percutaneous treatment in such patients. MATERIALS AND METHODS Between January 1994 and June 2010, a total of 176 patients with liver disease underwent liver transplantation; 119 recipients were included in this retrospective analysis. Median posttransplant follow-up period was 49 months. RESULTS Mean age was 43.0±12.7 years. Living donor liver transplantation (LDLT) and deceased-donor liver transplantation (DDLT) were performed in 71 and 48 patients, respectively. Duct-to-duct anastomosis and Roux-en-Y hepaticojejunostomy were performed in 68 and 51 patients, respectively. The overall incidence of posttransplant biliary complications was 36%; anastomotic biliary strictures were the most common biliary complications (42%), followed by biliary leakage (28%). On logistic regression analysis, duct-duct anastomosis was the only risk factor associated with the development of biliary complications (Odds ratio (OR), 3.346; p=0.005). Endoscopic and percutaneous treatment was successful in the majority of patients (81%), and the remaining 19% recipients underwent surgery for biliary repair. Endoscopic retrograde cholangiopancreatography (ERCP) guided drainage and balloon dilatation with stent placement were the most common treatment modalities. CONCLUSION Biliary complications were most frequent after liver transplantation; biliary strictures were the most commonly seen. The use of duct-to-duct anastomosis for biliary reconstruction is a risk factor for the development of biliary complications. Endoscopic and percutaneous treatment was successful in the majority of these patients.

Kidney Transplantation in Immunologically High-Risk Patients

An increased number of sensitized patients await kidney transplantation (KTx). Sensitization has a major impact on patient mortality and morbidity due to prolonged waiting time and may preclude live donor transplantation. However, recent reports have shown that KTx can be performed successfully using novel immunosuppressive protocols. This study presents our experience with patients displaying donor-specific antibody (DSA) (+). We enrolled 5 lymphocyte cross-match (LCM) negative (complement-dependent cytotoxicity) and panel-reactive antibody (PRA) plus DSA-positive patients mean fluorescein intensity [MFI] > 1000) who underwent living kidney donor procedures. All subjects were females and their mean age was 36.7 years. In our protocol, we started mycophenolate mofetil (2 g/d), tacrolimus (0.01 mg/kg) and prednisolone (0.5 mg/kg) on day -6. We performed 2 sessions of total plasma exchange (TPE) with albumin replacement and administered 2 doses of IVIG (5 g/d). On day -1, we added rituximab (200 mg). On the operation day and on day +4, the patients received doses of basiliximab. Serum samples were taken on days -6, 0, and 30 as well as at 1 year after transplantation. All patients displayed immediate graft function. Mean basal DSA titer was 5624 MFI. After desensitization, the MFI titers decreased at the time of transplantation to 2753 MFI, and were 2564 MFI at the 1st month and 802 MFI at 1st year. Three patients experienced acute rejection episodes (60%). After treatment for rejection, the average follow-up was 17 months and last creatinine levels were 0.6-0.8 mg/dL (minimum-maximum). In conclusion, KTx can be succesfully performed in sensitized patients displaying DSA. However, there seems to be a greater acute rejection risk. There is no consensus regarding adequate doses of IVIG or plasmapheresis treatments; furthermore, more studies are needed to clarify the safe MFI titer of the DSA.