Ahmet A. Balik

Late Complications of Incisional Hernias Following Prosthetic Mesh Repair

Abstract Background: Incisional hernias still continue to be a serious problem for surgeons. In this study, we aimed to investigate the effects of polypropylene mesh and mersilene mesh, which are frequently employed in incisional hernias, as well as the effects of their application techniques on late complications. Methods: Two-hundred-sixty-four open abdominal hernia repairs were performed between 1986–2000, using prosthetic materials: polypropylene mesh and mersilene mesh were used in hernia repair. Mesh was placed as onlay, underlay and sandwich techniques. Follow-up data were obtained from medical records. Results: Comparisons were made with respect to surgical techniques and to late complications such as recurrence, ente-rocutaneous fistula, intestinal obstruction, and infections. Enterocutaneous fistulas developed in two patients. Recurrence occurred in 6.4 per cent. Chronic infection and wound sinus formation occurred in 5 per cent. The causes of recurrence included smoking, cellulitis, chronic infection/sinus tract, upper abdominal localization, and obstruction. Fistula formation occurred in patients with no peritoneal prevention, which was statistically significant (p=0.012). Chronic infection/sinus tract was high in patients for whom mersilene mesh was used, and enterocutaneous fistula occurred in 2 patients. Conclusion: To prevent late complications, it is necessary to avoid the contact of mesh with bowel.

Intra-Abdominal Extrahepatic Echinococcosis

Abstract Twenty-seven patients who were treated surgically because of extrahepatic abdominal hydatid disease between 1981 and 1999 were retrospectively reviewed. Nineteen patients had coexistent hepatic cysts while 8 patients had only peritoneal cysts. The cysts were located in the spleen, pancreas, adrenal gland, mesentery of the intestines, ovaries, retroperitoneum, omentum, abdominal wall, rectovesical region, and the psoas muscle. Due to organ destruction because of large cysts in 8 patients, the involved organ had to be sacrificed. The other 19 patients were treated by a pericystectomy. No postoperative mortality or severe morbidity was seen. In conclusion, symptomatic or large cysts should be surgically treated. In cases suspected of having peritoneal spillage, antihelminthic drugs should be administered. In addition, small asymptomatic cysts may also be effectively treated with antihelminthics.

Hydatid cysts of the adrenal gland: review of nine patients.

Adrenal cysts are very rare lesions, especially with parasitic origin. But with the wider application of ultrasonography (US) and computed tomography (CT) more adrenal cysts are detected incidentally. To gain more insight into this entity, the records of nine patients with hydatid cysts of adrenal gland seen at our department from January 1980 till January 2002 are reviewed. There were four men and five women, and their ages ranged from 15 to 80 years (median: 41 years). All of the patients had unilateral cysts. Seven cysts were located on the right and two on the left side. Five of the cysts were primary and four were secondary. In three patients the cysts were found incidentally. The most common presenting symptom was pain, which was present in six patients. An indirect hemagglutination (IHA) test was positive in six cases. In all patients, US and CT successfully imaged all cysts, but the definitive diagnosis was made by macroscopic and microscopic examination of the cyst’s content. The patients were treated surgically. In all patients adrenal glands with the cystic masses were removed. The median follow-up period was 16 months (range: 6–64 months). No evidence of recurrence was found in any patient. It should not be forgotten that cystic masses of the upper abdomen might also originate from the adrenal gland. The etiology and nature of the cyst should be well researched, and appropriate treatment should be given as soon as possible. Surgical excision of the gland, including the cyst is the treatment of choice.

Effect of nitric oxide synthase inhibitor on experimentally induced burn wounds.

BACKGROUND Nitric oxide (NO) may have an important role in the healing of burn wounds. This study investigated the effect of NO on experimentally induced burn wounds by preventing NO synthesis. METHODS A total of 40 mice weighing 25 to 30 g were used in this study. The shaved skin on the back of the mice was immersed in 100 degrees C water for 10 seconds to achieve a partial-thickness scald burn. The mice were divided into two groups of 20. In group I (control group), 17.5 mg/kg of serum physiologic (placebo) was injected intraperitoneally two times a day for 15 days. In group II (study group), 17.5 mg/kg of aminoguanidine (NO synthase inhibitor) was injected intraperitoneally two times a day for 15 days. On day 15 of the burn, the animals were killed and the burn areas were investigated histologically. Histologic changes such as epithelial proliferation, abscess, collagen, and granulation tissue were evaluated. RESULTS Epithelial proliferation, formation of collagen, and granulation tissue with rich capillaries observed in the control group were statically significantly higher than those observed in the study group (z = -2.022, p < 0.05; z = -2.02, p < 0.05; and z = -2.022, p < 0.05; respectively). CONCLUSION We concluded that healing of the burn wound is delayed by preventing NO synthesis.

Ileosigmoidal Knotting: Outcome in 63 Patients

PURPOSE:This study was designed to review the outcomes of 63 patients with ileosigmoidal knotting.METHODS:Sixty-three, surgically treated patients (47 males; 74.6 percent) were reviewed retrospectively. The mean age was 45.6 (range, 7–75) years. The most common symptoms were abdominal pain and obstipation, and the most common signs were abdominal tenderness and distention. The preoperative diagnosis was obstructive emergencies in 49 patients (77.8 percent) and nonobstructive emergencies in 14 (22.2 percent).RESULTS:All patients underwent emergency laparotomy. The most common type of ileosigmoidal knotting was Type 1A in 30 patients (47.6 percent), in which the active ileum encircled the passive sigmoid colon in a clockwise direction. Fifty patients (79.4 percent) developed gangrenous bowel. Resection of gangrenous segments and enteroenteric or enterocolic anastomosis combined with the Hartmann procedure was the most preferred operation, used in 34 patients (54 percent). The mortality rate was 15.9 percent (10 patients), and toxic shock was the most frequent cause of death.CONCLUSIONS:Ileosigmoidal knotting is a rare but serious form of intestinal obstruction. Its preoperative diagnosis is difficult and may present as an obstructive or nonobstructive emergency. Early and effective resuscitation, prompt surgical intervention selected on the basis of clinical and operative findings, and effective postoperative intensive care are the basis of treatment.

Diagnosis and Surgical Treatment of Morgagni Hernia: Report of Three Cases

Morgagni hernia is a rare congenital disorder, which is usually asymptomatic, but may cause respiratory or gastrointestinal symptoms. We reviewed the clinical findings of three patients with a Morgagni hernia, diagnosed and treated in our department between 1997 and 2000. The Morgagni hernia caused various symptoms in all three patients and surgery was performed via posterolateral thoracotomy in two, and via laparatomy in one. The hernial defect was closed by primary suturing in two patients and by synthetic mesh in one. All three patients had an uneventful postoperative recovery. We believe that the transthoracic approach is an effective way of repairing Morgagni hernia.

Intrabiliary rupture in liver hydatid cysts: results of 20 years' experience.

Abstract To assess the diagnostic tools and results of treatment of biliary rupture observed in liver cyst hydatids, clinical findings of 562 patients with hepatic hydatid disease were reviewed. Imaging techniques were not very effective to determine intrabiliary ruptures. Rates of rupture sizes determined in the patients were as follows; 22 (%24.7) large, 38 (%42.7) small, and 29 (%32.6) occult. Most frequently utilized procedures for patients with intrabiliary rupture were Roux-en-y cystojejunostomy, tube drainage + omentoplasty, sutured fistula + omentoplasty, and sutured fistula + tube drainage. Of the total 25 external biliary fistulas, 21 closed spontaneously. Of the four fistulas that did not close, one was managed by internal drainage and three by endoscopic sphincterotomy. Preoperative diagnosis of biliary rupture in liver hydatid cyst allows early planning of operation and helps the surgeon design the operative strategy. In the treatment of cases with large rupture, internal drainage may be proposed.

Percutaneous drainage of hydatid cyst of the liver: long‐term results

BACKGROUND Previously surgical operation was the only accepted treatment for hydatid liver cysts. Recently percutaneous management has become more preferable because of its low morbidity rate and lower cost. PATIENTS AND METHODS In all, 101 patients harbouring 120 hydatid cysts of the liver were treated by percutaneous drainage between October 1994 and December 1997. Of these cysts, 89 were in the right liver and 31 in the left liver.Thirty-one patients had had previous operations for hydatid disease. All cysts had an anechoic or hypoechoic unilocular appearance on ultrasound scan. The mean dimension of the cysts was 7.5+/-2.9 cm (range 3-10.4 cm). All patients received oral albendazole 10 mg/kg perioperatively. After aspiration under sonographic guidance, cysts were irrigated with 95% ethanol. RESULTS The amount of cyst fluid aspirated was 220+/-75 ml and the amount of irrigation solution used was 175+/-42 ml. Four patients developed mild fever and three had urticaria. Mean length of hospital stay was 2.1+/-0.7 (range 1-4) days, and patients were followed up for 43-62 months (mean 54+/-5.4 months). Maximal cyst diameter decreased from 7.5+/-2.9 cm to 3.2+/-15 cm (p<0.001). Sonographic examinations revealed high-level heterogeneous echoes in the cyst cavity (heterogeneous echo pattern), while the cyst cavity was completely obliterated by echogenic material (pseudotumour echo pattern). DISCUSSION Most hydatid cysts of the liver can be managed successfully by a combination of drug therapy and percutaneous drainage.

Periampullary Diverticula Causing Pancreaticobiliary Disease

Our purpose was to determine if the presence of duodenal diverticula predisposes to the development of pancreaticobiliary disease. Between May 1999 and February 2001, 381 patients were examined by endoscopic retrograde cholangiopancreaticography. Of these patients, 51 had periampullary diverticula. In 27 patients the papilla was located inside the diverticulum (Group I), in 19 patients it was located at the edge of the diverticulum (Group II), and 5 patients it was located at a distance closer than 3 cm to the diverticulum (Group III). Seventeen patients in group I and 11 patients in group II had had a previous cholecystectomy. The overall incidence of biliary system stone disease was 22.2% in group I, 36.8% in group II, and 100% in group III. All patients were treated with endoscopic sphincterotomy and three (two in group I and one in group II) developed biliary system disease (cholangitis or pancreatitis). We think that sphincterotomy should be applied regardless of the presence of stone if the papilla is located inside or at the edge of the diverticulum. If the papilla is located 3 cm or more far for diverticulum, it should be considered within the frame of general sphincterotomy indications in the absence of stone disease.

Hydatid disease in childhood.

Abstract.To review the results of different modalities of treatment of hydatid disease of the liver (HDL) in pediatric patients, 31 children treated surgically between 1990 and 2000 at the departments of general surgery and pediatric surgery, Atatürk University School of Medicine, were reviewed retrospectively; 19 were male and 12 were female. The mean age was 8.4 years (range 4–12 years). The most common complaints were an abdominal mass and right-upper-quadrant pain, which were present in 35.5% and 77.4% of cases, respectively. Twenty-five cysts were in the right lobe, 2 in the left lobe, and 4 in both lobes; 8 patients had multiple hepatic cysts and 5 had coexisting cysts in other organs. Surgical procedures were: unroofing plus tube drainage (UTD); capitonnage; omentoplasty; and pericystectomy. Of the patients treated by UTD, 2 developed cholangitis and 1 developed a biliary fistula. Of the patients with capitonnage, 1 developed cholangitis. Surgery is still one of treatment modalities for management of HDL. Omentoplasty and capitonnage are the most effective modalities for the management of the cyst cavity.