Alper Parlakgumus

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

The purpose of this report was to determine the effectiveness of therapeutic plasma exchange (TPE) in preoperative preparation of patients with thyrotoxicosis scheduled for either thyroid or nonthyroid surgery. We retrospectively reviewed 11 patients with thyrotoxicosis and those who prepared surgery with plasmapheresis between 1999 and 2008 at our institution. Ten patients underwent thyroid surgery and one patient was operated for femur fracture during antithyroid drug treatment. The indications for plasmapheresis in all patients with severe thyrotoxicosis were poor response to medical treatment (seven patients), agronulocytosis due to antithyroid drugs (three patients), iodine‐induced thyrotoxicosis (Jodd Basedow effect in one patient), and rapid preparation for urgent orthopedic operation (one patient). After TPE, we observed a marked decrease in free thyroxin (FT3) and free triiodothyronin (FT4) levels; however, the decline in the biochemical values were not statically significant (P > 0.62, P > 0.15). Although both FT3 and FT4 levels remained above the normal limits in two of 11 patients, the signs and symptoms of thyrotoxicosis improved in all patients and no thyroid storm observed during the perioperative period. TPE can be considered a safe and effective alternative to prepare patients with thyrotoxicosis for surgery when drug treatment fails or is contraindicated and when emergency surgery is required. J. Clin. Apheresis, 2009.

Effects of a tissue sealing-cutting device versus monopolar electrocautery on early pilonidal wound healing: a prospective randomized controlled trial.

BACKGROUND: Monopolar electrocauterization produces thermal effects on neighboring tissues, causing tissue damage. Recently, tissue sealing-cutting devices, which are easy to use and achieve simultaneous selective sealing and cutting with less production of heat, have been used. OBJECTIVE: The aim of this study was to investigate the effects of a tissue sealing-cutting device vs monopolar electrocautery on wound healing in the early postoperative period after pilonidal sinus surgery. DESIGN: This study was a prospective randomized clinical trial. SETTING: This study was conducted at Military Hospital, Eskisehir, Turkey. PATIENTS: In total, 128 patients with chronic pilonidal disease were randomly assigned into 2 clinically comparable groups between December 2009 and June 2010. INTERVENTION: Pilonidal sinus excision was performed with monopolar electrocautery in the control group (n = 64) and with a tissue sealing-cutting device in the study group (n = 64). Data regarding wound healing, demographic variables, history, physical examination findings, defect dimensions, and scores for a visual analog scale were recorded. MAIN OUTCOME MEASURES: The main outcomes measured were surgical site infection, early wound failure (dehiscence), and unhealed wound rate. RESULTS: Wound infection and dehiscence rates were significantly lower (P = .01 and .02), but the duration of surgery was significantly longer (P < .01) in the tissue sealing-cutting group. The unhealed wound rate was 12.5% in the electrocautery group and 4.7% in the tissue sealing-cutting group (P = .01). When the distance from the lowest margin to the anus was 5 cm or less, wound infection and dehiscence rates were lower in the tissue sealing-cutting group (P < .01 and .03). LIMITATIONS: We could not obtain data regarding the cost-effectiveness of the instruments. CONCLUSIONS: A tissue sealing-cutting device in pilonidal sinus surgery yields better wound healing than monopolar electrocautery.

Atorvastatin for ovarian torsion: effects on follicle counts, AMH, and VEGF expression

OBJECTIVE(S) To determine if atorvastatin protects ovarian follicles against ischemia reperfusion (I/R) injury and to determine how anti-Müllerian hormone (AMH) and vascular endothelial growth factor-A (VEGF-A) expression is altered. STUDY DESIGN This experimental study was conducted at the Baskent University Animal Research Laboratory. Forty-four rats were arbitrarily assigned into four groups of 11 rats each. The control group underwent a laparotomy. The atorvastatin group received atorvastatin (10mg/kg/day), by oral gavage 7 days before and 7 days after the sham operation. The torsion group had bilateral torsion and detorsion of the ovaries. The atorvastatin+torsion group received atorvastatin (10mg/kg/day) 7 days before and 7 days after the torsion/detorsion operation. At day 7, the animals were euthanized and their ovaries were removed. Ovarian follicles were counted, and AMH and VEGF-A expression was determined. The Kruskal-Wallis, χ(2), or Fishers exact test were used when appropriate. RESULTS Primordial follicles (p=0.001), VEGF-A expression (p=0.018) and vascularization (p=0.02) were significantly higher in the atorvastatin group compared to controls. Primordial (p=0.002), primary (p=0.001), and secondary follicles (p=0.001), AMH expression (p=0.001), and vascularization (p=0.001) were lower in the torsion group compared with the control group. Primordial follicles (p=0.001), AMH (p=0.001) and VEGFA expression (p=0.001), and vascularization (p=0.001) were significantly higher in the atorvastatin+torsion group compared to the torsion group. CONCLUSION(S) Atorvastatin increased the primordial follicle pool and vascularization and protected primordial follicles and vascular structures against I/R injury.

Morgagni hernia: diagnosis with multidetector computed tomography and treatment.

PurposeWe aimed to retrospectively evaluate morbidity, mortality and treatment outcomes in 12 cases of Morgagni hernia diagnosed with multidetector computed tomography (MDCT) and treated appropriately.MethodsThis is a retrospective study and data on the demographics, presenting symptoms, MDCT images, operative approach, morbidity and mortality were collected from hospital records.ResultsOf 12 patients with a mean age of 60 years, ten were female. The diagnosis was made with MDCT before surgery. All hernias were unilateral and located in the right part of the thorax. The contents of the hernias were omentum and colon in the majority of the patients, and the contents of the hernia as diagnosed with CT was confirmed at surgery. Six patients had surgery. Of these, one had emergency surgery for hernia, two laparoscopic hernia repair, three transabdominal repair and one transthoracic repair.ConclusionsMDCT is a good imaging technique to be used before surgery in that it is fast and non-invasive, helps to make an accurate diagnosis of Morgagni hernias and provides detailed information about the contents of the hernia and accompanying complications. Modern surgical techniques, including laparoscopy, help to achieve the repair of Morgagni hernias safely with short hospital stay and with little morbidity and mortality.

Surgical treatment modalities for complicated aneurysms and pseudoaneurysms of arteriovenous fistulas

Purpose This study was designed to determine the clinical presentation, characteristics, and management of aneurysm/pseudoaneurysm formation (APF) in dialysis access fistulas. Methods The treatment methods and outcomes of 31 patients who underwent surgery for APF in dialysis access fistulas were retrospectively reviewed over a 9-year period. Results We performed 1558 operations for arteriovenous fistulas (AVFs) between 2000 and 2009 at our centre. Of the 1558 operations, 35 were carried out for APFs (2.2%) on 31 patients. Thirty of these operations were restorative. Twenty-two (71%) of these patients had their original access done elsewhere, and all corrective surgeries were performed at our hospital. Approximately 52% of the subjects were female, with a mean age of 45.7 ± 17 years. The mean duration of end-stage renal disease was 70.2 ± 51.5 months. The mean number of AVFs per patient was 2.2 ± 1.5. Synthetic grafts were used in five patients (16.1%). Most of the procedures were left-sided (67.7%) and brachial-cephalic fistulas (48.3%). Among 31 complications, 22 were arterial/venous aneurysms (71%) and nine were pseudoaneurysms (29%). Fourteen patients (46.6%) were treated by excision of the aneurysm and primary suture repair. The post-intervention primary patencies for all revised APFs were 68%, 56%, and 52% at 1, 6, and 12 months, respectively. Dysfunction of AVF (16.1%) and bleeding (12.9%) were the most encountered complications after aneurysmectomy. Conclusion Reformative operations should be considered in cases of urgency and irresponsiveness to endovascular surgery rather than closing the fistulas directly, as it prolongs the duration of AVF patency.

Factors affecting morbidity in urgent repair of abdominal wall hernia with intestinal incarceration in adults

BACKGROUND The aim of this study was to investigate factors that affect morbidity in adults with incarcerated intestinal hernia of the abdominal wall. METHODS 124 patients with a mean age of 61 ± 13.87 years (73 males) underwent emergency surgery for incarcerated intestinal hernia between March 1999 and March 2008. The median duration of the hernia was 5 years (0.1-30). Type and duration of hernia, accompanying diseases, surgical procedure, and operation-related complications were retrospectively evaluated. RESULTS Twenty-five patients (20%) had complications. Twelve patients (10%) had surgical site infection and 10 patients (8%) had septic complications. Four patients (3%) died in the postoperative period. Out of 40 patients developing strangulation, 18 underwent bowel resection. The only independent variable concerning bowel resection other than inguinal hernia was found to be ventral hernia (p=0.039). There was no statistical significance between duration of hernia and incarceration and complications. The rate of complications was significantly high in the patients with accompanying diseases (p<0.001). The relation between age and complications was also significant (p=0.034). Multivariate analyses showed high ASA scores as the only independent variable for development of complications (p<0.001). CONCLUSION Patients with comorbid diseases and high ASA scores should be informed about the elevated risk of complications, and scheduled surgery before the development of incarceration should be recommended.

Acute torsion of the gallbladder: a case report.

IntroductionTorsion of gallbladder is an uncommon cause of acute abdomen. Volvulus occurs along the long axis of the gallbladder mesentery, and according to the degree of rotation symptoms, and signs may vary.Case presentationA 79-year-old woman presented with a one-day history of acute onset of right upper abdominal pain. The patient underwent laparotomy with a preoperative diagnosis of acalculous cholecystitis with possible gangrene. At laparotomy, the gallbladder was distended, and multiple necrotic areas were observed. It was rotated more than 180 degrees clockwise around the mesentery, and cholecystectomy was performed.ConclusionCholecystectomy is the treatment of gallbladder torsion. Clinical signs and radiographic studies may be helpful to diagnose gallbladder torsion. Early diagnosis and surgical treatment lower the mortality of disease.

Scrotal calcinosis due to resorption of cyst walls: a case report

IntroductionScrotal calcinosis is a rare benign entity defined as the presence of multiple calcified nodules within the scrotal skin. There are controversies about the origin of this entity. In fact, it is still debatable whether scrotal calcinosis is an idiopathic growth or dystrophic calcification of dartoic muscles. It is also unclear whether scrotal calcinosis originates from inflammation of epidermal cysts affected by mild to moderate inflammation of mononuclear cells, from foreign body granuloma formation followed by resorption of cyst walls or from eccrine epithelial cysts.Case presentationWe report a 41-year-old male Turkish patient presenting with a 10-year history of scrotal tumours increasing slowly in size and number. Histopathologically, there was no epithelial lining around the calcified nodules, but there was fibrosis adjacent to atrophic stratified squamous epithelium.ConclusionResults of histopathological examinations suggested that scrotal calcinosis might have been due to resorption of cyst walls. Surgery remains the key for this problem. In cases of non-massive scrotal calcinosis, like the case presented here, excision of the nodules from the affected part of the scrotal wall and repairing the defect with horizontal stitches offer good cosmetic results without relapse.

Results of surgery in general surgical patients receiving warfarin: retrospective analysis of 61 patients.

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.

Effects of different doses of statins on liver regeneration through angiogenesis and possible relation between these effects and acute phase responses.

BACKGROUND We examined the effects of two doses of statins on liver regeneration through angiogenesis and its possible relation to acute phase responses. MATERIALS AND METHODS Seventy-two rats were randomly divided into three groups: controls; low-dose atorvastatin (0.5 mg/kg/d); high-dose atorvastatin (2.5 mg/kg/d). Statin was administered daily by oral gavage for 7 days. After atorvastatin treatment, all animals in the three groups underwent 70% hepatectomy. Thereafter animals were subdivided into three subgroups, to evaluate the characteristics of liver regeneration proliferating cell nuclear antigen (PCNA), angiogenesis (KDR/Flk-1 [vascular endothelial growth factor-2]) and acute phase response (serum interleukin [IL]-6) at 12, 24, and 72 hours. RESULTS At the 24 hours posthepatectomy, low-dose compared with high-dose atorvastatin increased liver regeneration (P = .004) and angiogenic responses compared also to controls (P = .026 and P = .059). However, there appeared no difference in IL-6 expression (P = .159). At the 72 hours posthepatectomy, low-dose atorvastatin treatment increased liver regeneration compared with controls (P = .047), but it showed no significant difference from the high-dose treatment (P = .109). Low doses of statin increased angiogenic responses compared with both control and high-dose animals (P = .016 and P = .002). Moreover, the high-dose group displayed decreased angiogenic responses compared with the control group (P = .044). Serum IL-6 expression was significantly greater among both low- and high-dose groups compared with controls (P = .005 and P = .003, respectively). CONCLUSIONS Low-dose statin treatment increased KDR/Flk-1-dependent angiogenesis, which resulted in an increased regeneration response. In contrast, high-dose statin therapy decreased angiogenesis without affecting long-term regeneration responses. Finally, statin therapy may contribute to liver regeneration due to prolonged IL-6 expression independent of statin doses.