Adnan Tas

Evaluation of two hemorrhoidectomy techniques: Harmonic scalpel and Ferguson's with electrocautery

AIM The prevalence of symptomatic hemorrhoidal disease is a common disease that usually needs surgery for treatment. Although conservative treatment is often enough for early stages, late stage disease usually needs surgical treatment. The most common and effective approaches used for conventional surgical treatment are harmonic scalpel (HS) and Fergusons with electrocautery hemorrhoidectomy (FEH). We aimed to use the HS device for hemorrhoidectomy in Grade III and Grade IV hemorrhoids and compare our results with FEH MATERIALS AND METHODS: Enrolled into the study were 151 patients who were operated for symptomatic Grade III-IV hemorrhoids. Patients were randomized into FEH and HS groups. The present review focused on comparing HS hemorrhoidectomy versus FEH with regards to operating time, postoperative pain, duration of disease, number of issued analgesics, length of hospital stay, time to return to normal activity, and postoperative complications. RESULTS The mean ages of patients who underwent HS and FEH were 34.1 ± 9.2 years and 33.7 ± 8.4 years, respectively. The average postoperative stay in the HS group was 1.0 ± 0.1 days and in the FEH group was 1.2 ± 0.4 (p = 0.001). The time of return to normal activity was less for the HS groups than for the FEH groups (10.6 ± 2.1 days vs. 16.0 ± 6.3 days; p = 0.001). The mean operating time of the HS and FEH groups was 16.8 ± 4.1 minutes and 25.5 ± 7.7 minutes, respectively (p = 0.001). The total analgesic doses for the HS group were 790 ± 206 mg, 619 ± 234 mg, and 30 ± 99 mg, and for the FEH group were 1096 ± 194 mg, 1000 ± 259 mg, and 40 ± 0 mg for postoperative Day 1, Day 7, and Day 28, respectively. There was no significant difference between the HS group and the FEH group in the terms of the number of excised hemorrhoid masses (2.0 ± 0.6 vs. 1.88 ± 0.6). CONCLUSION HS hemorrhoidectomy is safe and effective, causes less blood loss and postoperative pain, and fewer complications compared to FEH.

Anti-inflammatory efficiency of Ankaferd blood stopper in experimental distal colitis model.

Background/Aim: Ankaferd blood stopper (ABS) is a herbal extract that enhances mucosal healing. In this study, we aimed to investigate the efficiency of ABS in the treatment of experimental distal colitis. Materials and Methods: Twenty one male albino rats were divided into three groups: Sham control (Group 1), colitis induced by acetic acid and treated with saline (Group 2), colitis induced by acetic acid and treated with ABS (Group 3). At end of the 7th day of induction, all the rats were lightly anesthetized with intramuscular ketamine (8 mg/kg) and thereafter laparotomy and total colectomy were performed. The distal colon segment was assessed macroscopically and microscopically. In addition malondialdehyde (MDA), superoxide dismutase (SOD) and nitric oxide (NO) levels of the colonic tissue and changes in body weight were measured. Results: The MDA and NO levels of the colonic tissues and weight loss were significantly higher in Group 2 compared to Group 1 and Group 3. Microscopic and macroscopic damage scores were significantly higher in Group 2 and Group 3 than Group 1 (P: 0.001, P: 0.004, respectively). Although the microscopic and macroscopic damage scores in Group 3 were slightly lower than Group 2, the difference was not statistically significant. The SOD levels of the colonic tissues were not different between the three groups. Conclusion: Weight alterations and high-levels of the colonic tissue MDA and NO suggested that ABS might have anti-inflammatory effects on experimental distal colitis. However, this suggestion was not supported by histopathological findings.

Outcomes of laparoscopic versus open splenectomy

Purpose Laparoscopic techniques have gained wide clinical acceptance in surgical practice today. The laparoscopic approach has been established as the technique of choice for elective splenectomies performed on normal sized spleens. The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the TOBB University of Economics and Technology (ETU) Hospital and Kecioren Training and Research Hospital. Methods One hundred and thirty-five patients underwent splenectomy between January 2000 and July 2010. For comparison, the records of 130 patients undergoing splenectomy were evaluated for age, gender, hospital stay, time to start of diet, conversion rate, operation time and wound infection. Results Mean operation time means the time interval between surgeon commencing operation to end of operation. Mean operation time in patients treated by LS was 132 minutes and 121 minutes in open splenectomy (OS). Mean hospital stay was 5.65 days in patients undergoing LS and starting of diet was 1.21 days. In patients treated by OS, mean hospital stay was 9.17 days, starting of diet was 2.37 days. Four patients were converted to open surgery. Conversion rate was 6.4 percent. In the early post operative period (within 10 days of surgery) 9.2%, LS group had lower incidences of wound infection rate after surgery than OS group (4.8%, 7.4%, respectively; P = 0.06). Conclusion LS is a safe and effective alternative to OS for treatment of splenic diseases in patients of all ages.

Bismuth, moxifloxacin, tetracycline, lansoprazole quadruple first line therapy for eradication of H. pylori: A prospective study

Helicobacter pylori infection is the main cause of gastroduodenal ulcers and chronic gastritis and strongly associated with gastric malignancies such as adenocarcinoma and mucosa-associated lymphoid tissue lymphoma. The most commonly used first line eradication regimen is triple therapy including proton pump inhibitors (PPIs) and two antibiotics, mainly amoxicillin and clarithromycin for 7—14 days [1]. However, clarithromycin resistance is increasing. The threshold of clarithromycin resistance at which this antibiotic should not be used is 15—20%. Clarihtromycin resistance is reported as 17.5% in Southern European countries and 53% in Turkey [2,3]. In Turkey, success rate of standard PPI-based triple therapy has fallen to 50—60% in recent years because of clarithromicine resistance [4]. Therefore, bismuth containing quadruple therapy or quinolone (levofloxacin or moxifloxacin) based triple or quadruple therapies have been evaluated in several clinical trials as an alternative first line regimen to attend the acceptable achievement rate of 80% [1,5—8]. In Maastricht IV consensus report, it is reported that in areas of high clarithromycin resistance,

Topical application of ankaferd hemostat in a patient with gastroduodenal amyloidosis complicated with gastrointestinal bleeding

Amyloidosis rarely manifests itself as gastrointestinal hemorrhage, especially in the absence of systemic involvement. Despite urgent endoscopic and/or pharmacological therapy, bleeding due to gastric amyloidosis usually recurs after a short period and has considerable morbidity and mortality rates, even in patients undergoing gastrointestinal surgery. For this reason, there is a need for a therapeutic armamentarium for such cases that is effective, easily applicable and has minimal side effects. In this respect, ankaferd blood stopper (ABS) offers a well tolerated and effective alternative approach for these patients. Herein we would like to report a 77-year-old man who had massive bleeding from a gastric ulcer complicating primary gastroduodenal amyloidosis, in whom topical ABS was successfully applied.

Atypical pANCA as a marker of indeterminate colitis for the prediction of ulcerative colitis and crohn’s disease

SummaryAimThe aim of this study was to demonstrate that the presence of atypical perinuclear antineutrophil cytoplasmic antibodies (pANCA) in indeterminate colitis (IC) patients and the potential role of pANCA for predicting the patients either with ulcerative colitis (UC) or Crohn’s disease (CD) for UC and CD.Material and methodsOutpatients and inpatients from the hospital were retrospectively enrolled between April 2008 and December 2010. A total of 25 IC patients enrolled in the present study. Subsequently, 25 randomly selected serum samples were tested for pANCA in our laboratory. Determination of pANCA was performed by enzyme linked immunosorbent assay.ResultsMinimum follow-up was 12 months. The mean duration of disease was 20.52 months. The diagnosis was changed to UC in 13, to CD in 5 patients. The remaining 7 patients are still classified with IC, with mean disease duration of 21.29 months. Duration of disease differs statistically when comparing pANCA positive versus pANCA negative. A positive correlation was found between IC and disease location in our study.ConclusionPatients with an initial diagnosis of IC who have positive serology are given a definitive diagnosis of UC or CD, respectively, more often than patients with negative serology.ZusammenfassungZielZiel der Studie war es, die mögliche Bedeutung von atypischen ANCA bei Patienten mit unspezifischer Colitis (UC) in Bezug auf die Vorhersage einer Colitis ulcerosa (CU) oder einer Morbus Crohn (MC) zu prüfen.Material und MethodenIn einer retrospektiven Studie wurden aus der Zeit von April 2008 bis Dezember 2010 ambulante und stationäre Patienten unseres Spitals in die Studie aufgenommen. Insgesamt wurden bei 25 Patienten mit UC in der vorliegenden Studie aus 25 randomisert ausgesuchten Serum-Proben mittels eines ELISA Assays die pANCA im Serum bestimmt.ErgebnisseDas minimale Follow-up lag bei 12 Monaten. Die mittlere Krankheitsdauer bei 20,52 Monaten. Die Diagnosen wurden bei 13 Patienten im Beobachtungsverlauf zu CU und bei 5 Patienten zu MC geändert. Bei den restlichen Patienten blieb die Diagnose einer UC bestehen, wobei die mittlere Krankheitsdauer 21,29 Monate betrug. Es bestand ein statistisch signifikanter Unterschied bezüglich Krankheitsdauer beim Vergleich von Patienten mit positiven pANCA zu den pANCA negativen Patienten. Außerdem bestand in unserer Studie eine positive Korrelation zwischen der UC und der Lokalisation der Erkrankung.SchlussfolgerungenBei Patienten mit einer ursprünglichen Diagnose einer UC und positiven pANCA Nachweis kommt es häufiger zur definitiven Diagnose einer CU oder eines MC als bei Patienten mit UC und negativen pANCA Nachweis.

Loss of body hair as a side effect of albendazole.

To the editor, Th e side-eff ects of albendazole are few and tend to be mild. Alopecia and total body hair loss due to albendazole have been rarely described in the pertinent literature [1, 2]. A 70-year-old man was referred to our gastroenterology department with mild right upper quadrant abdominal pain. Physical examination at admission revealed liver about 2.5 cm below the rib (total mattie 15 cm), and other examination findings were normal. He was evaluated with transabdominal ultrasonography, which revealed several cystic lesions with diameter of 20–30 mm in the liver consistent with hydatid disease caused by echinococcus granulosus. Laboratory investigations revealed a high value of eosinophils (10%). Serologic testing confirmed the diagnosis. We decided to initiate the therapy with albendazole, 15 mg/kg/day. At 20th day of drug therapy he realized loss of all body hair (Figure). We stopped albendazole therapy. Th e patient improved all body hair one month after cessation of albendazole. Albendazole has in important role in the treatment hydatid disease caused by echinococcus granulosus [3, 4]. Th e side-eff ects of albendazole are multisystemic, such as hypersensitivity, renal, hepatic, hematologic and gastrointestinal (abdominal pain, nausea/vomiting) [1]. Our case showed hair loss associated with albendazole without other systemic side eff ects. In conclusion, albendazole may cause total hair loss. Fortunately, that adverse event is reversible and improve after cessation of the treatment.

Plasma Thrombin-activatable Fibrinolysis Inhibitor Levels Correlate with the Disease Activity of Ulcerative Colitis

Objective Patients with ulcerative colitis (UC) are at an increased risk for thromboembolic events, particularly in patients with extensive and active disease. To date, a few studies have been published on the role of thrombin-activatable fibrinolysis inhibitor (TAFI) in UC. However, there are no reports in the literature investigating the effect of UC treatment on plasma TAFI levels. Methods The plasma TAFI antigen levels were quantitatively determined using ELISA kits for 20 UC patients at activation and remission, along with 17 healthy controls. The association between the TAFI levels and inflammatory markers was assessed to determine UC activation. To predict and determine the activation of UC, the Truelove-Witts index and the endoscopic activation index (EAI) were used for each subject. Results The plasma TAFI levels were higher in UC patients at activation of the disease compared with the remission state and in healthy controls. Spearmans correlation analyses revealed that the WBC (r: 0.586, p<0.001), hsCRP (r: 0.593, p<0.001) and EAI (r: 0.721, p<0.001) were significantly correlated with the TAFI levels. The overall accuracy of TAFI in determining UC activation was 82.5% with a sensitivity, specificity, NPV and PPV of 80%, 85%, 81% and 84.2%, respectively (cut-off value: 156.2% and AUC: 0.879). Conclusion The present study demonstrates that the TAFI levels are elevated in the active state of UC. The assessment of TAFI levels in patients with UC in conjunction with other markers of inflammation may provide additional information for estimating UC activation and severity.

Serum nitric oxide levels in patients with benign and malignant biliary disease: a prospective single center study.

Background: Despite advances in new diagnostic modalities, the differentiation of malignant from benign causes of biliary obstruction still remains difficult. The nitric oxide (NO) system is considered to be an important component in mediating cytokine activation of macrophages in inflammation. It also modulates tumorigenesis and regulates cell proliferation, angiogenesis, survival, and DNA repair. Although NO and its role in pancreatobiliary disorders has not been studied previously, the present study is designed to evaluate NO synthesis and metabolism in patients with biliary obstruction and to determine its usefulness in differentiating between benign and malignant causes of biliary obstruction. Materials and Methods: Seventy-nine consecutive patients (60 malignant and 19 benign) with a history of biliary obstruction either with a benign or a malignant cause and 23 age-matched and sex-matched controls were included in this prospective study. NO metabolites, and conventional inflammation and tumor markers were determined. Results: In patients with malignant biliary obstruction (MBO), serum NO metabolites were found to be significantly elevated (P<0.001). The receiver operating characteristic analysis showed that an NO level of 1.095 was the best cut-off value for predicting a malignant biliary stricture with a sensitivity of 78.3% and a specificity of 84.2% (area under the curve=0.821). Correlation analysis suggested that carbohydrate antigen 19-9 and carcinoembryonic antigen levels were correlated with NO levels for differentiating benign from malignant cause of biliary obstruction. Conclusions: Serum NO-associated tissue injury might be associated with the development of pancreatobiliary neoplasia by creating a local environment that is enriched with reactive oxygen species, cytokines, and other growth factors that may promote endothelial cell apoptosis. Moreover, serum NO levels may be used as an adjunctive marker to identify malignant causes of the obstructive jaundice.

Meckel's diverticulitis in Amyand's hernia

The presence of the appendix within an inguinal hernia has been referred to as ‘Amyand’s hernia’ to honour Cladius Amyand surgeon of King George II. Amyand was first to describe the presence of a perforated appendix within the inguinal hernial sac in 1735 [1]. Most cases are diagnosed intra-operatively rather than pre-operatively. Appendicular diverticulitis in an Amyand’s hernia was rare [2]. We present a case of an inguinal hernia containing both the Amyand’s hernia and a Meckel’s diverticulum. An 86-year-old man presented with a 20-year-old history of a bilateral inguinal mass. The mass in the right groin enlarged and became painful lately. The clinical examination of the abdomen was normal. There were swellingsin both groins, the right side being larger and tender, but the skin showed no signs of inflammation. The white blood cell count and the temperature were normal. Ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. The operation was performed by an anterior approach through an inguinal incision. A sliding hernia was found with the caecum comprising a hernial wall and the appendix protruding through the hernial sac being edematous and hyperemic (Fig. 1). An appendicectomy was done. Further exploration of the bowels revealed a Meckel’s diverticulitis which was managed by a wedge resection. We proceeded with the hernia repair and planted a mesh according to the Lichtenstein technique. Histopathologic examination showed a normal appendix vermiformix but revealed a Meckel’s diverticulitis. Post-operative recovery was uncomplicated; the patient was discharged 2 days after admission and had no complaints till now. The presence of the appendix within an inguinal sac is an uncommon condition and is referred to as ‘Amyand’s hernia’. The incidence of having a normal appendix within the hernial sac is 1 % [1, 3]. Most of the cases of Amyand’s hernia occur on the right side, probably as a consequence of the normal anatomical position of the appendix, and also because right-sided hernias are more Wiener klinische Wochenschrift The Central European Journal of Medicine Wien Klin Wochenschr (2012) 124:288–289 DOI 10.1007/s00508-012-0153-x