Adil Kartal

Endoscopic clipping versus band ligation in the management of bleeding esophageal varices.

Background: The effectiveness of endoscopic clipping in the hemostasis of bleeding esophageal varices and the eventual variceal eradication was compared with that of band ligation. Methods: Forty patients were enrolled in the study in a prospective manner, 19 of whom received endoscopic clipping (group I) and the remaining (n = 21 patients) received endoscopic band ligation (group II). All patients in this study presented with bleeding from esophageal varices. The patient characteristics (age, sex, Child–Pugh score, variceal grade) were comparable in the two groups. After initial hemostasis, the patients were assigned one of the two forms of endoscopic therapy which was continued in the follow-up sessions until varices were eradicated. Early and late results were compared. Results: Initial hemostasis was achieved in all patients in group I but two patients in group II required clip ligation for initial hemostasis because of the failure in band ligation. Those two were treated with band ligation in the follow-up sessions. A total of 224 clips in 53 treatment sessions and 296 bands in 82 treatment sessions were placed in group I and group II, respectively. The rates of complete variceal eradication were 89% and 76% in group I and group II, respectively (p > 0.05). The median number of required treatment sessions for complete eradication of the varices was significantly lower in group I than group II (3 versus 4, p = 0.013). Three patients from group I (15%) and seven patients from group II (33%) were readmitted for variceal bleeding during the follow-up period (p > 0.05). Conclusions: With the advantages of high initial hemostasis rate, decreased risk of rebleeding, and fewer treatment sessions needed for variceal eradication, endoscopic clipping is as effective as band ligation, or perhaps more effective in the treatment of bleeding esophageal varices.

Long-term results utilizing the unroofing technique in treating hydatid cysts of the liver

PurposeThe aim of this study was to present the long-term follow-up results of liver hydatid cysts treated with unroofing, together with a review of the related literature data.MethodsOf 700 liver hydatid cyst patients examined and treated at Selcuk University Meram Medical Faculty, General Surgery Department, between 1985 and 2007, 650 had accessible data and the unroofing method had been applied in 189 of them. The clinical and laboratory findings, stages, operations, and complications of patients treated with unroofing were reviewed. In particular, the resolution of residual cyst cavities over time after the application of this method was evaluated using computed tomography.ResultsFour hundred and thirty-six (67.07%) of the cases were female [mean age: 35 (range: 10–73) years] and 214 (32.9%) were male [mean age: 46 (range: 12–76) years]. Of the 189 cases treated with unroofing and followed by tomography, the data of 144 were documented. Cavities were classified into five groups (A-E) according to their postoperative appearance.ConclusionsUnroofing is an easy approach and it does not require extensive experience. This technique is recommended for peripherally localized cysts but may also be applied to those more deeply situated. Unroofing should be applied as deeply as possible and the residual cavity should also be as shallow as possible.

RF-Assisted Cystectomy and Pericystectomy: A New Technique in the Treatment of Liver Hydatid Disease

Background: Radiofrequency (RF) energy has been used for ablation and resection of liver tumors. Purpose: To present a new technique for the treatment of liver hydatid cyst disease. Material and Methods: Two patients with liver hydatid disease treated with RF energy cauterization and surgical resection are presented. Cystectomy was performed in a female patient aged 35 years and pericystectomy was carried out in another female patient aged 55 years using RF energy cauterization. Blood was not needed during the operation. RITA® System (RITA Model 1500 RF Generator, RITA Medical Systems, Inc., USA) was used during the procedure. Conclusion: Cystectomy and pericystectomy in liver hydatid disease can be successfully performed with the assistance of RF energy.

Effect of Octreotide (Sandostatin 201-995) on Bile Flow and Bile Components

Octreotide (Sandostatin 201-995) has aninhibitory effect on gastric, intestinal, and pancreaticsecretions and hepatic and splachnic blood flow. Weexamined the effects of octreotide on bile flow and bile components in 10 patients with T-tubecholedochostomy. A Fogarty balloon catheter was inserteddistal to the T-tube of these patients for measurementof bile flow and bile components. Bile samples were obtained to analyze bile acid, phospholipid,lipoprotein, and cholesterol, and bile flow measurementswere performed every 15 min for a period of 90 minbefore study and after normal saline and octreotide administrations. While octreotide had aninhibitory effect on bile flow, the concentrations ofbile acid, phospholipid, and lipoprotein in bile wereincreased with octreotide.

Internal Herniation as a Major Cause of Intestinal Obstruction

Objectives: To evaluate internal herniation as a rare cause of intestinal obstruction.Materials and Methods: Files of 18 cases, operated due to internal herniation between 2000 and 2006 at Selcuk University, Meram School of Medicine, General Surgery Department, were reviewed retrospectively. Sixteen patients (88.8%) were male (mean age: 58.2 years; range: 42–67) and 2 were female (mean age: 56.5 years; range: 52–61).Cases were grouped according to the location of internal herniation, and the clinical findings and applied treatment strategies were evaluated. Results: All patients were taken into surgical operation after preoperative preparations were completed. Findings were as follows: 6 cases of paraduodenal internal herniation, 4 of internal herniation through a defect in the terminal mesoileum, 2 of herniation through a defect in the falciform ligament, 2 of herniation through a defect in the omentum majus, 1 of herniation to the recessus over the bladder, 2 of herniation through a defect in the transverse mesocolon and 1 iatrogenically caused internal herniation through a defect in the mesojejunum. Conclusion: In an adult patient with findings of intestinal obstruction, diagnosis is difficult. Most cases presented to date are incidental findings during laparotomy, and surgical treatment is necessary.

Effectiveness of collagenase in preventing postoperative intra-abdominal adhesions

INTRODUCTION The purpose of this study is to investigate the effectiveness of Collagenase clastridiopeptidase an enzyme preparation used in enzymatic debridement in preventing adhesions brought about by peritoneal damage. METHODS The study covers a total of 40 rats in 4 groups each having 10 rats. Group 1: The control group. Group 2: Normal saline group. Group 3: Sterile Novuxol group. Group 4: The group where the intraperitoneal and systemic effects of sterile Novuxol were investigated. Adhesion frequency and grades were scored on the post-op 11th day according to Granat. Blood work including hemoglobin, aspartate aminotransferase, alanine aminotransferase, urea, creatinine, and albumin level measurements were performed. Toxicity was investigated histopathologically through samples taken from the liver and the peritoneum from Group 4. RESULTS Adhesion frequency was found to be 80% on the right and 90% on the left for Group 1, while it was 50% on both left and right for Group 2, and 30% on the right and 10% on the left for Group 3. Adhesion stages were found to be 1: 2.35 ± 1.42 for Group 1, 0.31 ± 1.15 for Group 2, and 0.20 ± 0.41 for Group 3. Adhesion stage of the Sterile Novuxol Group was lower than all the other groups (p < 0.05). Biochemical and hematological parameters were similar in all groups (p > 0.05). Histopathological analysis revealed no hepatotoxicity. CONCLUSIONS According to the results of our study, we believe that Sterile Novuxol can be a good anti-adhesive agent considering its ease of use, non-toxicity, and effectiveness.

Effect of Laparoscopic Cholecystectomy on Platelet Aggregation

Abstract. The purpose of this study was to investigate the effect of laparoscopic cholecystectomy on platelet function. We operated on 40 women with symptomatic gallbladder stone, 20 of whom (study group) underwent laparoscopic cholecystectomy and 20 of whom (control group) open cholecystectomy. Patients with a history of bleeding, abnormal platelet count, or systemic disorders and those who were on salicylates, heparin, or oral anticoagulants were excluded. Blood parameters were checked at the beginning and the end of the operation, including platelet aggregation using adenosine 5′-diphosphate (ADP), collagen, and ristocetin in a whole-blood aggregometer. Platelet aggregation was evaluated by percent aggregation. Platelet aggregation due to collagen and ristocetin increased significantly at the end of the operation in the study group (p < 0.001). Aggregation due to ADP did not differ significantly from the start to the end of the operation. Control group results did not show any differences. Although the clinical findings of aggregated platelet are not frequently observed in practice, we suggest that laparoscopy increases platelet aggregation.

The management of hepatic hydatid cyst cavity by overlapping.

The obliteration of the cyst cavity after evacuation is a controversial procedure in hepatic hydatid disease. There is no ideal surgical technique which can be used in all hydatid cyst cavities. Since 1989 we have been using a new technique, which we call overlapping, in the treatment of suitable cases of hepatic hydatid cyst cavities. The technique depends on the obliteration of the cavity without drainage. After evacuating the hydatid material from the cavity, instillation of the cystic cavity is performed with scolecidal agent (silver nitrate solution, 0.5%). The cavity is opened along its long axis. The pericyst is prepared, and the upper edge is sutured to the bottom of the cavity with absorbable stitch (modified external collapse). Before doing this, if there is no possibility of operative ultrasonography, the cavity is punctured with a fine needle to evaluate any dangerous areas. Then the other edge of the pericyst is laid down beside the collapsed one and sutured to the former with the same technique. The term “overlapping” stems from this second procedure. During the operation, we decide which pericyst will collapse and which one will overlap. Before overlapping, openings between the cavity and biliary tree should be found and if there are any, they should be secured. In cases of large and multiple openings, T-tube choledochostomy is necessary. We applied overlapping to 31 of 43 hepatic hydatid cysts (ranging from 5 to 17 cm in diameter, with a mean of 12 cm) in 19 patients. Twenty-four of 31 cysts had partial pericystectomy before overlapping. Three cystic cavities were connected to the biliary tree. Because of a large connection, T-tube choledochostomy was added in one case. We have not seen any complications, either infection or biliary fistula. The results of the obliteration of cavities were excellent in 15 cysts. There were no residual cavities

Transanal electrovaporisation of rectal tumours.

OBJECTIVE To present our early results with endoscopic transanal electrovaporization of rectal tumours. DESIGN Retrospective study. SETTING Department of Surgery, Faculty of Medicine, University of Selçuk. SUBJECTS 10 patients, 4 with malignant and 6 with benign lesions. INTERVENTIONS Vaporization of the tumour using a new ridged roller electrode, the VaporTrode, and a standard 24F urological resectoscope. MAIN OUTCOME MEASURES Morbidity and recurrence. RESULTS There were no complications and all adenomas were vaporized completely. 2 patients with obstruction required a further treatment 3 and 5 months later because of recurrence. Median duration of operation was 22.5 minutes (range 10-38) and median duration of hospital stay was 3 days (range 1-4). CONCLUSION The VaporTrode is a safe and potentially useful tool for transanal excision of rectal tumours, the long term efficacy of which should be tested in larger series of patients.

Bile duct ischemia developing after reconstruction of the hepatic artery during the Whipple operation

A pancreaticoduodenectomy is a surgical procedure with a high morbidity and mortality rate. The injury of the hepatic artery may occasionally lead to intraoperative bleeding. Repair of the injured hepatic artery is of great importance in terms of maintaining the vascular supply of the liver. We report a case with an injury of the hepatic artery that was successfully reconstructed with the gastroduodenal artery and then developed a biliary leak due to bile duct ischemia at an early stage. A 33-year-old women complaining of right upper quadrant pain was found to have a solid pseudopapillary tumor of the pancreas. She underwent an immediate pancreaticoduodenectomy, and her hepatic artery was injured during the operation. The arterial ends were sutured with primary anastomosis, because they could be aligned without any tension. The biliary leak occurred on postoperative day 2. We detected bile duct ischemia and reanastomosed the artery. The patient was discharged on postoperative day 8. Surgeons should be prepared for anomalies of the peripancreatic vascular structures during pancreaticoduodenectomy. Computed tomography angiography should be considered to reveal these anomalies before the surgery. Insufficiency of the biliodigestive anastomosis due to bile duct ischemia in the postoperative period should be kept in mind, even in cases of successful repair.